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FREE Safer Sex Supplies Order Form

Please complete this form to order safer sex supplies from Health Promotion and Prevention Education. Orders will be picked up at the HPPE Office: B124 in the basement of the Seymour Union

  • Name Name *
  • My gender identity is: *
    My gender identity is:
  • My sexual orientation is: *
    My sexual orientation is:
  • My racial identity is: *
    My racial identity is:
  • I am an RA and this order is for my residence hall and not for my personal use? *
    I am an RA and this order is for my residence hall and not for my personal use?
  • I would like to request which of the following safer sex supplies *
    I would like to request which of the following safer sex supplies
  • I have a latex allergy and require latex-free products: *
    I have a latex allergy and require latex-free products:
  • I would like to request which of the following safer-sex supplies: *
    I would like to request which of the following safer-sex supplies:
  • All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

    I would like to pick up my order from the POS office at which time? *
    All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

    I would like to pick up my order from the POS office at which time?
  • I would like to receive an email with information about STI/HIV testing services? *
    I would like to receive an email with information about STI/HIV testing services?
  • I would like to receive an email about Pre-Exposure Prophylaxis (PrEP).

    PrEP is a once daily oral medication designed for people at risk for HIV. It is proven to be highly effective for preventing the spread of HIV. *
    I would like to receive an email about Pre-Exposure Prophylaxis (PrEP).

    PrEP is a once daily oral medication designed for people at risk for HIV. It is proven to be highly effective for preventing the spread of HIV.
  • I would like to receive text notifcations when my condom order is ready to pick up? *
    I would like to receive text notifcations when my condom order is ready to pick up?
  • Cell-Phone Number (I understand that standard data usage charges may apply) Cell-Phone Number (I understand that standard data usage charges may apply) * - -
  • Draw or Type
    I understand this is a legal representation of my signature. Clear
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