Request Form

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email

Would you prefer the Naloxone plastic box or a canvas bag (kit contents are exactly the same)?(Required)

Naloxone plastic box
Canvas bag

Do you prefer to receive the information inside of your Naloxone kit in English or Spanish?(Required)

English
Spanish

By signing this form, I acknowledge:

I have read, reviewed, and understand how, when, and to whom to administer Naloxone and certify that I did receive the training as identified above.(Required)

I have read, reviewed, and understand the terms

I understand that administering Naloxone is not a substitute for professional medical care.(Required)

I understand

I understand that the importance of calling 911 after administering Naloxone, it is still vital that the victim receive an immediate medical evaluation.(Required)

I understand

I understand that I may be protected under the Pennsylvania Good Samaritan Law when requesting medical attention for someone who has suffered an opioid overdose.(Required)

I understand

In addition to the prior acknowledgements, I waive any claims which may arise from the administration of Naloxone, either by myself or another individual who I have authorized to administer Naloxone. I indemnify and hold harmless York Opioid Collaborative, their partners, employees, and representatives for any loss, damage or liability associated with the administration of Naloxone, whether it is administered by me, or an individual I have authorized to utilize Naloxone.(Required)

I agree

CAPTCHA

Step 1 of 3

By signing this form, I acknowledge:

Useful Links

Important Info

Contact Info