At-home HIV Test Sign-up Form
Thank you for signing up for an HIV at-home testing kit! Please fill out this form to the best of your ability. These kits are intended for people living inside Lane County, Oregon, ages 17+. They will be dropped off to you via no-contact in an unmarked package.  Please note, your kit will include a $20 Target gift card.

Your kit will come with instructions on how to use the kit and how to report your results to sign up for a $30 Target gift card . See our website for details: https://transponder.community/hiv-testing-kits/

If you have any questions about the program please email us at wellness@transponderoregon.org, or call or text us at ‪(541) 321-6454‬.

We remove any personally identifiable information before we share our data with HIV Alliance.
Email *
Contact Information
We collect basic information to create your unique user ID, get your supplies to you promptly, and contact you in case of an issue. 
Please provide the first two letters of your last name. *
Please provide the first two letters of the city you were born. *
What is your date of birth? *
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What is your preferred method of communication? *
Can we identify ourselves when we contact you? (We may say "TP" or "TransPonder".)
 *
What is your preferred email? *
What is your phone number? *
FULL ADDRESS--number/street/city/zip. (Please be as complete as possible so we can send you a kit.) Note: we can only deliver kits within Lane County. *
Any special instructions for delivery? Please provide any instructions for how to find you and where to leave your package safely. *
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