Wicomico County Health Department Naloxone Online Registration Form

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CONFIDENTIALITY: Please note that none of your information will be shared

Trainings are now being offered virtually or in person. After submitting the form, We will contact you to set up a day and time.

Opioid overdoses affect families, loved ones, and communities. Learn how to respond to an overdose by attending a virtual training and receiving your NARCAN kit for FREE.

Be a Hero, Save a Life.

Be a good Samaritan-get Narcan trained so you can save a friend, neighbor, someone's family member, etc.

Would you prefer an in person or a virtual training? *

In Person

Virtual via Google Meets

First Name *

Last Name *

Address (must be Wicomico County Resident) *

Phone Number *

Birthday (Month, Day, Year) *

Gender

Man

Woman

Non-Binary

Genderqueer

Another Gender

Transgender

Decline to Answer

Email Address *

Race / Ethnicity

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Another Race, Ethnicity, or Origin

Unknown / Decline to Answer

Please check which category best describes your reason for attending and wanting/needing Narcan

Occupation

Volunteer Work

Family Member (of a loved one who could potentially be in an overdose situation)

Social Experience (someone with lived experience or knows someone that struggles with substance misuse )

Law Enforcement

Unknown / Decline to Answer

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