Friday ORP Trainee Registration Form

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Healthy
Charles County

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My Community
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Environmental Health
LBHA
- Naloxone and the Overdose Response Program
LBHA
- Naloxone and the Overdose Response Program
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Education
LBHA
- Go Purple Charles County
- Naloxone and the Overdose Response Program
Education
Health Professionals
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  - Naloxone and the Overdose Response Program
- Lock It Up
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Health Professionals

Home
About Us
Services
LBHA
- Local Behavior Health Authority
  - Naloxone and the Overdose Response Program
- Lock It Up
Education
Health Professionals

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About Us
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LBHA
- - - Local Behavior Health Authority
      - Naloxone and the Overdose Response Program
    - Lock It Up
Education
Health Professionals

"*" indicates required fields

1. Is this your first time receiving naloxone?

Yes

No

I am not receiving naloxone today

2. Gender (optional, choose all that apply)

Man

Woman

Non-Binary

Genderqueer

Another Gender

Decline to Answer

3. Do you identify as trans? (optional)

Yes

No

Decline to Answer

4. Race/Ethnicity (optional, choose all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Another race, ethnicity, or origin

Decline to Answer

5. Age in Years (optional, choose only one)

<18

18 – 24

25 – 34

35 – 44

45 – 54

55 – 64

65 – 74

75 – 84

84+

Decline to Answer

6. Which category best describes your reason for obtaining overdose education and/or naloxone? Please choose only one.

Occupation

Volunteer Work

Family Member

Social Experience

Law Enforcement

7. How would you like to receive your free naloxone?

Pick up at the Charles County Department of Health

Mail to my address (Maryland residents only)

Mailing Address

Please enter the address you would like your free naloxone mailed to:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Signature*

Name*

8. In order to receive the online link and confirmation of training, provide an email address

Email*

How Do I...

Enroll In Health Insurance
Apply For WIC
Request Medical Transportation
Apply For Permits
Find Mental Health/Substance Use Services
Request A Dental Appointment

Learn About Immunizations
See if I Qualify For Cancer Screening Services
File An Environmental Health Complaint
Request Public Property Records
Quit Using Nicotine Products

4545 Crain Highway
White Plains, MD 20695
Phone: 301-609-6900
Hours: Mon-Fri 8 AM – 5 PM

ADMINISTRATION

Health Officer
Dianna E. Abney, M.D.

MISSION

To protect, promote, and improve the health, safety, and environment of Charles County residents.

VISION

A healthier Charles County

PARTNER LINKS

Charles County Government

Charles County Public Schools

Maryland Department of Health

University of Maryland Charles Regional Medical Center

The College of Southern Maryland

Healthy Charles County