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Free Menstruation Products Ordering Form

Please complete this form to order safer sex supplies from Health Promotion & Prevention Education and the Center for Gender and Sexual Diversity. Orders will in the HPPE office: Dailey Hall 103


**ALL ORDERS** are subject to product availability.

  • 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 ordering for? *
    I am ordering for?
  • I would like to request a bulk order containing which of the following menstruation products? *
    I would like to request a bulk order containing which of the following menstruation products?
  • I would like to request which of the following menstruation products? *
    I would like to request which of the following menstruation products?
  • If you requested a menstrual cup, which size would you prefer?
    If you requested a menstrual cup, which size would you prefer?
  • 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 HPPE/CGSD 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 HPPE/CGSD office at which time?
  • I would like to receive text notifications when my menstrual products order is ready to pick up? *
    I would like to receive text notifications when my menstrual products 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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