Safety Support Material Distribution
Pomona Valley Pride strives to actively find ways to combat risky behavior and support safety. Please fill out the form below in order to access Narcan (Naloxone) Nasal Spray, Fentanyl Test Strips or Condoms.
What type of Safety Support Material do you need? (note you can select more than one)
*
(Narcan) Naloxone Nasal Spray
Fentanyl Test Strips
Condoms
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
What is your age?
*
What is your Gender Identity?
*
What is your race/ethnicity?
*
Is this the first time you've received a Naloxone (Narcan) Nasal Spray?
*
Yes
No
Is this the first time you've received a Fentanyl Test Strip?
*
Yes
No
Have you overdosed in the past 12 months?
*
Yes
No
Have you witnessed someone overdose in the past 12 months?
*
Yes
No
Do you know about our Substance Use Disorder & Risks Program? THRIVE (Teaching Health, Resilience, Identity, Vitality & Empowerment) meets every 1st/3rd Thursday from 4 - 5:30pm at Pomona Valley Pride.
Yes
No
I'm Interested
What is the main reason for obtaining safety support materials?
Submit
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