Steve Rummler HOPE Network · Organization Registration

Organization Information

Please include information about the organization requesting naloxone kits, training, standing order, fentanyl test strips, etc.

Organization Name

*

Address of Organization

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

*

MN Residents

General Email Address

*

Verify Email

*

General Phone Number

Website

Does Your Organization Need Any of the Following? [Select all that Apply]

Naloxone Kits

Fentanyl Test Strip Kits

Overdose Response Training

None of the Above

Notes for Staff:

Please share any details about your interest in partnering with SRHN.

Name

*

First Name

Last Name

Title

Direct Line

*

Direct Email

*

Verify Email

*