Gender-Affirming Items Request Form

Gender-Affirming Items Request Form

[MASSACHUSETTS RESIDENTS ONLY] Below is a list of gender-affirming items that our center offers. If you prefer to pick up the item at our center, please specify what time and date (at least 2 weeks from your completion of this form) in the "suggestions & comments" box at the bottom of this page. [2 ITEMS ONLY]
I am completing this form...
Please make sure to enter the information for the person whom you are completing this form, including the address they want the items shipped to.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
E-mail
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
LGBTQ+ Identity
Optional and used to help our organizations create data for grant funding and future programming.
Ethnicity and race
Optional and used to help our organizations create data for grant funding and future programming.
Item Selection

Please choose UP TO TWO (2) ITEMS in total.
Binders

Other
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES (ex. XS, M, 6XL etc.)
Design/Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
These binders are completely customizable and therefore have more specifications to fill out than the other options listed above. If you choose this option, please contact our center and we will walk you through the process.
Binding Tape

Other
Size(s)
Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
This warning appeared because you have chosen a selection from "Binding Tape." BINDING WITH CLING WRAP, BANDAGES OR TAPE CAN DAMAGE TISSUE AND BREAK RIBS. If you still want to choose this item, please AGREE to acknowledge you are informed on the possible harms of binding tape and will not hold ELYSARC or Rebel Cause, Inc. accountable if any issues arise from the use of this binding tape. (Please follow the binding instructions that will be inserted into your package).
Boxers and Briefs

Other
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES (ex. XS, M, 6XL etc.)
Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
Packers & STP Devices

Other
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES (ex. XS, M, 6XL etc.)
Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
Pack Gear

Other
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES (ex. XS, M, 6XL etc.)
Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
Makeup and Skincare

Other
Color (if applicable)
Look at websites and write the color listed under your item. BE AS SPECIFIC AS POSSIBLE.
Wigs/Extensions/Hair

Other
Please copy and paste the link with your specifications listed in paranthesis (after the link). Make sure the item you choose is less than $80.00 after tax.
Gaffs and Tucking Underwear/Tape

Other
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES (ex. XS, M, 6XL etc.)
Design/Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
Bra
Size
CHECK WEBSITE FOR AVAILABLE SIZES (ex. 32A, 36DD, etc.)
Color
Style
Ex. Bandeau, wired/not wired, bralette, T-shirt bra, etc. BE AS SPECIFIC AS POSSIBLE. Can write "no preference."
Breast Forms, Bra Inserts and Body "Enhancers"

Other
Nipple Size
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES.
Color(s)
Look at websites and write the color/design name as listed under your item. BE AS SPECIFIC AS POSSIBLE.
Silicone Scar Sheets
Size(s)
CHECK WEBSITE FOR AVAILABLE SIZES.
Suggestions & comments
Please list any other gender-affirming items we could offer next time or let us know when you would like to pick up your items from our center (if you did not list your address). Please choose a date at least 2 weeks from the date of filling out this form.
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Gender-Affirming Items Request Form

Item Selection