FREE Menstrual Products Order Form

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FREE Menstrual Products Order Form

Please complete the form below in full to order free menstrual products. **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 ordering for? *

I am ordering for? I am an RA ordering for my residence hall This is my personal order I am ordering for a department on campus
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 an assortment 100 products; including 50 tampons and 50 pads I would like 50 tampons I would like 50 pads
I would like to request which of the following menstruation products? *

I would like to request which of the following menstruation products? I would like 10 tampons I would like 10 pads I would like a menstrual cup (if available)
If you requested a menstrual cup, which size would you prefer?

If you requested a menstrual cup, which size would you prefer? Small (20mL) Large (25mL) Does not apply
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 like to receive a text notification when your order is ready for pickup? *

Would like to receive a text notification when your order is ready for pickup? 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: Male Female Trans-Female/Transfeminine Trans-Male/Transmasculine Gender Queer Gender Non-Conforming Gender Expansive Demi-Gender Agender I prefer not to say 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 I prefer not to say 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 I prefer not to say My racial identity is not listed My racial identity is not listed
By completing this form, I understand that the information that I submit in this form will be used to fill my order. Personal information disclosed will remain private. *

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.