For Maryland Residents Only Thank you for your submission. Sex Male Female Genderqueer Non-Binary Transgender Man Transgender Woman Decline to Answer Other If other, please specify: Race/Ethnicity - check all that apply: American Indian or Alaskan Native Black or African American Native Hawaiian or Other Pacific Islander White or Caucasian Asian Hispanic or Latino Age <18 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 84+ Please choose which category best describes your reason for obtaining overdose education and training: Occupation Volunteer Work Social Experience Family Member Law Enforcement Please choose your overdose education and training reason. How did you learn of this service? Radio TV Newspaper Flyer Social Media Other Please correct your How did you learn of this service?. If other, please specify: First Name Please correct your first name. Middle Name Last Name Please correct your last name. Mailing Address Please correct your Mailing Address. Date Please enter the date. Electronic signature confirming receipt of naloxone Please enter your electric signature. In order to be notified about delivering your Narcan kit please provide an email address and/or phone number: Email Address Phone Number Submit
