Houston County AED and Naloxone Wall Box Request Form

Question Title

* 1. Organization Name and Address

Name:

Address:

Question Title

* 2. Primary Contact:

Name

Telephone

Question Title

* 3. Check the equipment you would like to request:

AED

Naloxone Wall Box

Question Title

* 4. Please describe how your organization plans to utilize the equipment you are requesting

Question Title

* 5. Please type your first and last name here indicating that this information is accurate to the best of your knowledge:

Thank you for taking the time to fill out our request form. Each application will be reviewed by the Houston County Opioid Settlement Collaborative for approval.