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Naloxone by Mail Request Form

If you live in Jackson, Josephine or Klamath County, fill out the form below and we will mail you a life-saving Naloxone kit.​ All personal information gathered in this form is strictly private and never shared outside of Max's Mission Naloxone by Mail program.​

Date of Birth
Month
Day
Year

(Demographic information helps us better understand who we’re reaching, where the greatest needs are, and how we can improve our efforts to best provide life-saving resources in Jackson, Josephine and Klamath communities.)

Race/Ethnicity (Optional)
Gender (Optional)
Male
Female
Non-Binary
Transgender
Decline to State
Other
Multi-line address
Have you received naloxone from Max's Mission before?
Yes
No
If yes, was the naloxone used to reverse an overdose?
Yes
No

By submitting the Naloxone by Mail Request Form, you consent to receive occasional email or direct mail communications from Max’s Mission. You may opt out of these communications at any time by following the unsubscribe link provided.

Report an Overdose Reversal

Have you used a Max’s Mission naloxone kit to reverse an opioid overdose? If so, we invite you to share your experience by submitting an overdose reversal report. Reports can be submitted anonymously, in both English and Spanish, and no identifying information is required. The information you provide helps us better understand the nature of overdose in our community. Each opioid overdose recovery story provides vital, real-time data that guides our outreach efforts, helps secure funding for no-cost naloxone distribution, and ultimately supports the goal of preventing the needless tragedy of death caused by opioid overdose. No personal information is required - just your honest input.

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1117 East Main Street Suite 3, Medford | 541-499-8485

P.O. Box 1145, Jacksonville | 458-225-9760

720 Rogue River Hwy, Grants Pass | 541-499-8108

3815 S. 6th Street Ste 200, Klamath Falls | 541-499-8012

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Klamath Jobs for You - Max's Mission supported employment center

3255 Washburn Way Ste 5, Klamath Falls, OR | 458-302-1604

Max's Mission © 2025

Max's Mission is designated as a 501(c)(3) - 990 Tax Form

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