Condom Club Enrollment

Condom Club Enrollment

To receive your FREE condoms by mail, please provide the following information:
IMPORTANT: If you are currently experiencing a medical emergency or think you were exposed to HIV within the last 72 hours, please seek immediate care at your local emergency room or urgent care facility.
Today's Date*

MonthDayYear
Date
First and Last Name*
Date of Birth*

MonthDayYear
Date
Age
Phone Number
Format: (000) 000-0000.
Mailing Address (At this time we are unable to accommodate orders from outside of Arkansas)*

Mailing Address

Street Address Line 2

CityState

Zip
Email*
example@example.com
How often would you like condoms mailed to you?*

Every 3 MonthsOne-Time Shipment (no automatic shipments)
Sex Assigned at Birth*

MaleFemale
Current Gender Identity*

MaleFemaleTransgender (Male to Female)Transgender (Female to Male)Transgender UnspecifiedDeclineOther
Sexual Identity*

StraightBisexualGayLesbianPansexualAsexualOther
Race*

AsianBlack/African AmericanWhiteNative AmericanNative Hawaiian/Pacific IslanderDon't Know/Not SpecifiedDeclineOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoDecline
Additional Resources
Would you like to receive information about testing for HIV, Hepatitis C, or Sexually Transmitted Diseases (STDs)?*

YesNo
Would you like to receive information about PrEP, a medication for HIV prevention?*

YesNo
Would you like to receive information about Arcare?*

YesNo
To receive additional information as requested above, please retype your email address below:
Please verify that you are human*
Should be Empty:

Condom Club Enrollment

Additional Resources