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Application Form to Order a Narcan Emergency Box for Your Public Establishment

Contact Name

By checking this box and submitting this form, I confirm that I am an authorized representative of the establishment listed below, 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 Narcan trainings as schedule permits.  I also understand that my site may be listed on the public access listing on the Erie County Opiate Epidemic Task Force website.  I agree to visually inspect the Narcan Emergency Box at least once per week and resupply with Narcan as needed.