FREE Safer Sex Supplies Order Form

Please complete the form below in full to order free safer sex supplies. **All orders are subject to product availability.**

All orders require a minimum of one business day notice. If you place an order after 4pm, M-F this timeframe will be delayed.

If you have any questions, please email prevention@brockport.edu.

Once your order is filled, it will be available for pickup on the first floor of Dailey Hall across from The Pantry. Dailey Hall is located between the Academic Success Center & Hazen Hall, near the red statue on campus.

Name Name * First Last
Email *
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 Yes, I am an RA No, I am not an RA; this is a personal order
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 would like an assortment of all safer sex supplies (mixture of external (100)/internal (25)) condoms including non latex, dental dams (25), finger cots (50), gloves (20), and lubricant (100) External condoms (100) Variety Pack and Including Non-Latex Internal condoms (25) Finger Cots (50) Dental dams (25) Gloves (20) Lubricant (100)
I have a latex allergy and require latex-free products: *

I have a latex allergy and require latex-free products: Yes No Unsure (You will be provided 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: External Condoms (25): An external condom (sometimes referred to as a male condom) is a thin, protective sheath that fits snugly over the penis or sex toy during sex. The external condom is often made of latex, but latex-free options are made of polyisoprene. Internal Condom (25): An internal condom is a soft, loose-fitting pouch that's inserted into the vagina or anus before sex to prevent pregnancy and/or sexually transmitted infections. The internal condom is latex free and are made of polyurethane and synthetic latex. Dental Dam (15) A dental dam is a thin, flexible, square piece of latex that helps prevent the spread of STIs and other germs during oral sex. Dental dams are easy to use. Place one over your or your partner's vulva and/or anus so that it creates a barrier between the mouth and genitals Finger Cots (25) The finger cot, also known as the finger condom, is a latex sheath designed to fit over a finger tip to approximately the base of the finger. Finger-cots are typically used to cover cuts and open wounds on fingers. Gloves (10) Gloves should be worn if there are any cuts, recent tattoos, hangnails, dermatitis, eczema, and other conditions present on the hands that may increase the risk of blood and open wounds. Lubricant (25) Lube reduces friction, so lessens your risk of injury during sex. And if you're using condoms, lube also makes it less likely that it'll break or fall off, therefore increasing your protection against STIs including HIV Flavored Condoms (5): An external condom (sometimes referred to as a male condom) is a thin protective sheath that fits snugly over the penis or sex toy. The external condom is often made of latex. SINCE THESE ARE FLAVORED, THEY ARE FOR ORAL SEX ONLY
All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

Please select the day/time below that you plan to pick up your order. *

All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

Please select the day/time below that you plan to pick up your order. Monday (1-5PM) Tuesday (1-5PM) Wednesday (1-5PM) Thursday (1-5PM) Friday (1-5PM)
Would you like to receive a text notification when you order is ready to pick up? *

Would you like to receive a text notification when you order is ready to pick up? Yes No
Cell-Phone Number (I understand that standard data usage charges may apply) Cell-Phone Number (I understand that standard data usage charges may apply) * - ### - ### ####
My gender identity is: *

My gender identity is: Cisgender Transgender Gender expansive Non-Binary Gender non-conforming Agender My gender identity is not listed My gender identity is not listed
My sexual orientation is: *

My sexual orientation is: Heterosexual Gay Lesbian Bisexual Pansexual Demisexual Asexual My sexual orientation is not listed My sexual orientation is not listed
My racial identity is: *

My racial identity is: American Indian or Native Alaskan Asian Pacific Islander Black Biracial Latino/a/x Multi-racial Middle Eastern/North African Native Hawaiian White My racial identity is not listed My racial identity is not listed
By completing this form, I understand that my personal information submitted in this form will be used to complete the terms of my safer sex supplies request. My information will remain private and it will be used for no other reason than to complete this request. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

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FREE Safer Sex Supplies Order Form