Receive My Narcan Web Form

Please use this only for pre-recorded training videos. This is not the registration form for the monthly Zoom training sessions.

Thank you watching the pre-recorded Narcan training video. Please complete this form in order to ensure delivery or pick-up of your free Narcan kit. If you live in New Paltz (12561), one of the surrounding townships, or within an area where we have volunteers who can deliver, your kit will be dropped off at the physical address you provide below. If we are unable to deliver in-person, a kit will be mailed to you (for residents within the Mid-Hudson Valley Region of New York). Please make sure the home address provided above is correct. Thank you! If you
Name *

First Name Last Name
Email Address *
Physical Address (No PO Box) *
City *
Mailing Address (for postal delivery) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
If you prefer to pick up your kit, please choose one of our current sites
Would you like to learn more about Harm Reduction supplies available? (ie. fentanyl test strips, safe use kits, safe sex kits, linkage to syringe access programs)

Yes No
How did you hear about this resource? *

Google Search Friend Social Media Coffee Cup Sleeve
Next Steps: If you live in New Paltz, one of the surrounding townships, or within an area where we have volunteers who can deliver, your kit will be dropped off at the physical address you provided above. If we are unable to deliver in-person, a kit will be mailed to you. Please make sure the home address provided above is correct. Thank you!
Should be Empty:

Please use this only for pre-recorded training videos. This is not the registration form for the monthly Zoom training sessions.