Safer Sex Kits
Full Name
*
First Name
Last Name
Affirmed/Preferred Name
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
My pronouns are:
They/Them
She/Her
He/Him
Other
Phone Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
Address (Deliveries are available)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which items are you interested in receiving? (Check all that apply)
*
Condoms-Assorted
Non-Latex Condoms
Lube
Internal ("Female") condoms (latex free)
Dental Dams (while supplies last)
Take-home HIV test kit
Flavored Condoms
What is your preferred method of contact? (Check all that apply)
*
Email
Phone Call
Text Message
Are you interested in learning more about our programs, groups and/or our newsletter?
Yes
No
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