Training, Presentation and Narcan Request Form

Training, Presentation and Narcan Request Form
Please fill out and submit the form below. We'll contact you as soon as possible to confirm the request.
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization (if applicable)
Location of Presentation or Training

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Adult Services (General Presentation)"What is Recovery Coaching, and what are the Benefits for Participants" (Presentation for Providers)"What is Recovery Coaching, and what are the Benefits for Participants" (Presentation for Participants)Stigma and Substance Use Disorder TrainingStigma, Opioid Use Disorders, and Medication Assisted Treatment TrainingOpioid Overdose Reversal Training (Narcan kits requested)Opioid Overdose Reversal Training (Narcan kits not requested)Narcan kits onlySACADA informational materialSACADA In-Office tourAgency tourOther
In personVirtualNo preference
EnglishSpanishBoth
30 minutes1 hour1.5 hours
Please select two (2) date and time preferences no earlier than 2-3 weeks from this submission date. We will try our best to accomodate your preferred selection.
Date of Request (Preference 1)

MonthDayYear
Date
Time of Request (Preference 1)
Date of Request (Preference 2)

MonthDayYear
Date
Time of Request (Preference 2)
Expected Number in Attendance
Number of Narcan Requested
Please indicate date and pick up method. Please include any other information here.
Is there anything else we need to know about this request. Please include what technology is available to us, if applicable.
Is there anything else we need to know about this request?
Signature
Thank you for your request! You will be contacted shortly. For more information, please email Jose Martinez at jmartinez@sacada.org or Craig Lambaria at clambaria@sacada.org.
Should be Empty: