FREE Menstrual Products Order Form
Questions? Email prevention@brockport.edu.
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Menstrual Product Order
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Student Information
This program is available for Brockport students only. Faculty, staff and departments can contact facilities or work within their department to make these products available.
Please answer the questions below and note that all products are while supplies last. Most orders are filled within 1 business day. Students will receive a notification when their order is ready for pickup (1st Floor, Dailey Hall, across from The Pantry).
Student Name
Student Name
*
First
Last
Student Email
*
Please select the statement that best describes you.
*
Please select the statement that best describes you.
Student ordering for myself
RA ordering for my residence hall
Requested Products - RA Order (Check all that apply)
*
Requested Products - RA Order (Check all that apply)
50 tampons
50 pads
Requested Products - Individual Order (Check all that apply)
*
Requested Products - Individual Order (Check all that apply)
10 Tampons
10 Pads
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