Become a Narcan Host Box Partner

Become a Narcan Host Box Partner

Complete the application to help expand life-saving overdose prevention resources in your community.
Organization / Contact Information
Business or Organization Name
Primary Contact Name
Title / Position
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Website or Social Media (if applicable)
Proposed Host Box Location
Physical Address of Proposed Narcan Host Box Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County
Type of Location

Other
Please describe where the Narcan Host Box would be installed
Property Authorization
Are you the property owner for the location where the Narcan Host Box would be installed?
If you are not the property owner, provide the property owner or authorized representative’s name and contact information.
Has the property owner approved placement of a Narcan Host Box at this location?
Accessibility & Safety
Will the Narcan Host Box be publicly accessible?
If access is limited, please explain the available hours
Is the installation area visible and well lit?
Is there security camera coverage near the proposed location?
Is the area protected from direct weather exposure?
Community Need & Interest
Why would this location benefit from a Narcan Host Box?
Have overdoses, medical emergencies, or emergency response incidents occurred nearby before?
How did you hear about The Lemon Aide Project or our Narcan Host Box Program?
Anything else you would like us to know?
Host Site Responsibilities
Review and confirm
Final Agreement
Digital Signature / Full Legal Name
Date Submitted

MonthDayYear
Date
Should be Empty:

Become a Narcan Host Box Partner

Organization / Contact Information

Proposed Host Box Location

Property Authorization

Accessibility & Safety

Community Need & Interest

Host Site Responsibilities

Final Agreement