Reusable Period Kit Form

Reusable Period Kit Form

Cloth Pad & Menstrual Cup Kits
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Country *
PayPal Email (used for shipping only)*
example@example.com

Please answer the following*

	Yes	No	Short Notes
Have you received a period kit from us or another charity before?
You are responsible for paying for the shipping of your kit only. Do you agree to pay the shipping fee?
Selling of donated items is unethical. If you no longer need the kit, we request you send it back so we can help others in need or give the items to someone else struggling with period poverty. Do you agree to not sell donated items from this kit?
Do you have access to facilities to wash your reusable menstrual products on a regular basis?

Please answer the following*

	Answer
Number of people in your household
Household monthly income

Which kit would you want?*

	Yes	No
Menstrual cup Kit (1 menstrual cup & 4 cloth liners)
6 Cloth pads (in the length and absorbency you request)

Kit Extras *Limited supplies, please only ask for what you are in need of, options may vary

	Yes	No
Wet Bag (storage bag to hold used pads until wash day)
Pad Wrapper (fits 1-2 pads, good for short trips out of the house)
Cloth Wipes
Drying Strap (hang drying pads after washing)
ILP's (innerlabial pads help direct flow to pad to prevent leaks off ends of pads)
Cloth Tampons (cotton reusable tampons)
Chest/Breast Pads
Soap Bar
Detergent (small travel amount)
Dental Hygiene (toothbrush, toothpaste, floss)
Shampoo or hair care supplies (leave note with what you need)
Deodorant
*Extra cloth pads (Will have flaws, they dont affect function)

Underwear *Leave size needed in notes

	Yes	No	Size
Do you need underwear
If we have them would you like period underwear?

Cloth Pad Kit Info. Please check the LENGTH you need.

	Yes	No	Short Notes
Short (~6-9")
Medium (~10")
Long (11+")
*Unsure of length need (we will send a variety)

Cloth Pad Kit Info. Please check the ABSORBENCY you need.

	Yes	No	Short Notes
Light
Moderate
heavy
*Unsure of absorbency you need (we will send a variety)

Menstrual Cup Info. (only if you applied for a menstrual cup kit) *Choose cervix height & cup size.

	Yes	No
Low cervix height
Medium height cervix
High cervix
Unsure of cervix height
-Small Cup (lighter- moderate flow)
-Large Cup (heavier flow)

Would you like a gender neutral kit?

	Yes	No	Short Notes
Gender neutral

Would you be okay with adult prints/style of pads? *MUST be 18+ to receive these.

	Yes	No	Short Notes
Okay with adult prints

Would you be okay with accepting gently used cloth pads? *These are stripped and sanitized and look like new. Used pads offer a wider variety of styles and fabrics.

	Yes	No
Okay with gently used
New pads only

Please let us know if there's any other information you'd like to share with us.
Please upload a picture of your ID. (We only use this to verify you're a real person. We never share this information with anyone else & is deleted after verifying.)*

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Thank you for filling out our application.

We will email you within a month with the status of your application. In the meantime, if there's anything you need, please let us know. We appreciate your patience as our volunteers work through the applications.
Please verify that you are human*
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Reusable Period Kit Form

Thank you for filling out our application.