Condom Request Form     
Residence Halls, Student Organizations, Peer Health Educators, and Campus Departments are welcome to request condoms for your events and presentations.

Requesting condoms for personal use? Please stop by the Well-being & Health Promotion office located on the 3rd Floor of Calpulli Center, Suite 3200.
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information about you...
Name *
Phone Number *
Email *
Organization you represent *
Date of Event *
年
/
月
/
日
Title of Event *
Description of Event *
How will you distribute condoms? *
Requesting condoms...
*
25
50
75
100
none, thank you
How many condoms are you requesting?
requesting lubricant...
*
10
20
30
40
50
none, thank you
How many lubricant packets are you requesting?
*
5
10
15
20
none, thank you
How many Dental Dams are you requesting?
requesting educational materials...
25
50
none, thank you
Condom instructions
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respectful distribution...
By checking "yes", I agree to distribute these condoms in a respectful way. This includes offering them in a way that people may refuse them. *
必填
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