Application Form for Becoming a Community Access Narcan Site

Instructions: Please complete and submit the form below. 

Site Address
Contact Name

Permission: By submitting this form, I confirm that I am an authorized representative of the establishment listed above, and that the site personnel agree to keep a limited supply of Narcan/naloxone on the premises, collect necessary distribution paperwork, and to refer interested individuals to comprehensive community trainings as schedule permits.  I also understand that my site will be listed on the public access listing on the Erie County Opiate Epidemic Task Force website.

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