Condom Request

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Through our partnership with Cempa Community Care, we offer condoms mailed directly to anyone who is 18+ and lives or goes to school in our service area.

If you are not in our service area or are under the age of 18, you can reach out to your local health department to get access to condoms.

Our service area includes the following 18 counties:
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Language
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What county do you currently live or go to school in?* This field is required.
Bledsoe, TN
Sequatchie, TN
Bradley, TN
Rhea, TN
Franklin, TN
Catoosa, GA
Grundy, TN
Dade, GA
Hamilton, TN
Murray, GA
Marion, TN
Walker, GA
McMinn, TN
Whitfield, GA
Meigs, TN
DeKalb, AL
Polk, TN
Jackson, AL
Other
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Since you do not live or go to school in our 18-county service area, you can reach out to your local health department for additional information and resources.
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Date of Birth* This field is required.
Date
Month
Day
Year
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Date
Date
Month
Day
Year
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Age
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Since you are under the age of 18, you can reach out to your local health department for additional information and resources.
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Name* This field is required.
First Name
Last Name
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Gender* This field is required.
Female
Male
Non-Binary
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Email Address* This field is required.Email will only be used for follow up if needed and email marketing updates IF you opt-in. If you don't have an email, please put no@email.com.
example@example.com
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Would you like to be signed up to receive our quarterly email newsletter?* This field is required.
Yes, subscribe me to the newsletter.
No
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What type of condoms do you need?* This field is required.Latex, external condoms - 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. This type of condom is made from latex. A latex condom should NOT be used by individuals who have a sensitivity or allergy to latex. Non-latex, external condoms - 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. A non-latex condom is typically made either from polyurethane, polyisoprene, or in some rare cases lambskin. This type of condom is used by individuals that have a sensitivity or allergy to latex. Internal condoms - A small nitrile (soft plastic) pouch (sometimes called a female condom) that is put inside the vagina. These condoms are latex-free. **Internal and external condoms should not be used at the same time.**
Latex External Condoms
Latex-Free External Condoms
Latex-Free Internal Condoms
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Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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How did you hear about A Step Ahead Chattanooga?* This field is required.
I'm an existing client
ASAC Staff, Event, or Education Class
Advertising
Co-Worker, Friend, or Family
Google Search
Health Department
Medical Office or Medical Provider
Social Media
Other
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Have you ordered condoms from us before?* This field is required.
Yes
No
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Would you like to receive an email when your order has been mailed?* This field is required.
Yes
No
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By submitting this form, you confirm the accuracy of the information provided, including that you are 18 or older, and consent to A Step Ahead Chattanooga mailing condoms to the address provided.
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Submission Date* This field is required.
Date
Month
Day
Year
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