Free Condom Kit Request Form
For DeKalb County, Georgia residents only. Only (2) orders per address can be placed in a 30-day period.
Your name
*
First Name
Last Name
Your email address
*
Confirmation Email
example@example.com
Where to send condom kit
*
Street Address
Street Address Line 2
City
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Back
Next
Completing the next five items is voluntary. We are asking for this information for data purposes. For each item, you can choose “Prefer not to answer.”
Your sex assigned at birth (please select)
Male
Female
Prefer not to answer
Your current gender identity (please select)
Male
Female
Transgender: male to female
Transgender: female to male
Non-binary/Gender non-conforming
Prefer not to answer
Your sexual orientation (please select)
Asexual
Bisexual
Gay
Heterosexual/straight
Lesbian
Pansexual
Queer
Questioning
Prefer not to answer
Other
Your race (please select)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Your ethnicity (please select)
Of Hispanic or Latino origin
Not of Hispanic or Latino origin
Prefer not to answer
How did you first hear about the free condom kit program? (please select)
*
DeKalb Public Health staff member
DeKalb Public Health website (dekalbpublichealth.com)
Facebook
Instagram
X (formerly Twitter)
Word of mouth
Don’t remember
Other
Type of condom kit you are requesting (please select)
*
Kit containing latex condoms of mixed sizes, lubricants and dental dams
Kit containing non-latex condoms of mixed sizes, and lubricants
Number of kits requested (please select)
*
Please Select
1
2
What is your age range?
Under 15 years
15-19 years
20-29 years
30-65 years
Over 65 years
Decline to state
I would like to get emails about upcoming events:
Yes
No
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Should be Empty: