School Blossom Bag Request Form
Complete this request form for Blossom Bag school distribution. Use the Phone Number field type for the phone input.
School Information
School Name
*
School District / Charter Network
School Address
*
City, State, ZIP
*
Grade Levels Served
Name of Person Completing Request
*
School Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Role and Distribution Details
Title/Position
*
School Nurse
Principal / Administrator
Counselor
Teacher
Social Worker
Other
Title/Position - Other (please specify)
Where will the Blossom Bags be kept/distributed?
*
School Nurse/Clinic
Counselor's Office
Administrative Office
Other
Where will the Blossom Bags be kept/distributed - Other (please specify)
Request Amount and Menstrual Product Context
How many Blossom Bags are you requesting this month?
*
1
2
3
4
5
Does your school currently provide menstrual products to students?
*
Yes
No
Limited supplies
Are you requesting more than the standard 5 Blossom Bags this month?
*
No
Yes
If yes, how many additional bags are requested?
Partner Recognition and Follow-Up
Would your school like to be recognized as an Official Blossom Bag School Partner?
*
Yes
No
May The Sacred Flower Inc. recognize your school on our website and/or social media as a participating Blossom Bag School Partner?
*
Yes
No
Would your school like information about period-preparedness workshops offered by The Sacred Flower Inc.?
*
Yes
No
Program Follow-Up Acknowledgment
*
I understand.
Agreement - Name
*
Agreement - Title
*
Agreement - Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: