Medication Lock Box Request Form for Organizations

Medication Lock Box Request Form for Organizations
If approved, your organization will receive up to 7 lock boxes by mail. Lock boxes will only be distributed to organizations within South Dakota. Please allow 1-2 weeks for delivery.

Upon approval, please understand that you will need to document each time you give out a lockbox. You will recieve a link to submit this information.

**Please note: We are not able to send lockboxes to a PO Box.
Is your organization located in or primarily serving residents of South Dakota?*

YesNo
This program is for organizations located in or primarily serving South Dakota. If you are outside of South Dakota, get connected with local services in your area by dialing 211 or visit 211.org.
Organization Name*
Organization Point of Contact*

First NameLast Name
Email*
Phone*
Physical Address (No POX boxes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Is Mailing Address different?*

NoYes
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your organization's type of work / industry*
Plan for distributing lock boxes*
Should be Empty: