JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
EFV Free Overdose Prevention Training
Participate in this free overdose prevention training and learn how to prevent death by overdose! Those who successfully complete the course will be awarded a certificate and a FREE Naloxone Kit.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Choose 1 Training Session (each session is 1 hr)
*
Monday, May 20, 2022 (2:00 to 3:30 pm)
Wednesday, June 15, 2022 (5:00 pm to 6:15 pm)
Wednesday, July 20 2022 (5:00 pm to 6:15 pm)
Wednesday, August 17, 2022 (5:00 pm to 6:15 pm)
Wednesday, September 21, 2022 (5:00 pm to 6:15 pm)
Wednesday, October 19, 2022 (5:00 pm to 6:15 pm)
Wednesday, November 16, 2022 (5:00 pm to 6:15 pm)
Wednesday, December 21, 2022 (5:00 pm to 6:15 pm)
What is your date of birth?
Date
Age Group
*
14 - 17 yrs old
18 - 26 yrs old
27 - 35 yrs old
36 - 45 yrs old
46 - 54 yrs old
55 + yrs old
Other:
Is this the first time you've received or purchased a Naloxone/Narcan kit?
*
Yes
No
Why would you like to receive a kit?
*
I'm worried that someone I know will overdose OR that I will overdose.
I work with people who use drugs as part of my job.
Just in case I see someone overdose.
Other:
Required
Are you Hispanic or Latino/a
*
Yes
No
Don't know/Not sure
What is your race? Please select all that apply.
*
American Indian
Asian
Black or African American
Native Hawaiian or pacific Islander
White
Do not know
Other:
Required
What is your current gender
*
Woman or Girl
Transgender Woman or Girl
Man or Boy
Transgender Man or Boy
Non-Binary Person
Gender Nonconforming Person
Not Sure Questioning
Prefer not to say
Other:
What was your sex at birth?
*
Female
Male
Intersex/ambiguous
Prefer not to say
Other:
How would you like to receive your Naloxone/Narcan Kit?
*
Pick-up
Delivered to address listed above
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of East Flatbush Village, Inc..
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
×
Advertisement