HV Regional Virtual Narcan Training Registration Form
This registration is for a web-based zoom Narcan training project being held on Wednesday, September 2, 2020 at 7:00PM. Please complete the following registration form to secure your spot for the training.

PLEASE NOTE: Narcan kits can only be promised to residents of Columbia, Delaware, Dutchess, Greene, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester counties. Individuals from outside those counties are welcome to sit in on the training, but a Narcan kit cannot be promised.

PLEASE NOTE: Registration closes at 6:00PM on the night of the training. If you register after 6:00PM, your registration will be moved to the next monthly training date.
Email Address (A zoom link will be sent to this email address 24 hours prior to the training) *
Full name *
Physical Address (No PO Box) *
City/Town & State *
Zip Code *
County *
Phone Number *
Ethnicity (Information will be used for grant purposes only)
Would you like a Narcan kit? *
How would you like to obtain a Narcan kit? *
Would you like to learn more about Harm Reduction bags available? (ie. fentanyl test strips, safe use kits, safe sex kits, linkage to syringe access programs, medication disposal packets, at-home medication disposal bags) *
Required
Do you understand that Narcan kits can only be promised to residents of Columbia, Delaware, Dutchess, Greene, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester counties. Individuals from outside those counties are welcome to sit in on the training, but a Narcan kit cannot be promised. *
Next Steps: An email will follow providing the date and time of the next training, and a link to access it. Please expect this link 24 hours prior to the training.
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