TDOR Self Care Box Request Form

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This is a form to request a self care box sent to your home on or around Trans Day of Remembrance.

These boxes are reserved for trans and gender non-conforming folks in Charlotte, NC and surrounding areas who are mourning and remembering their kindred.

Boxes can be delivered or you can opt to pick yours up after your online request.

Pick-up Location:
Time Out Youth Center
3800 Monroe Rd., Charlotte, NC 28205

Pick-up Days and Times:
Wednesday, Nov. 18 through Friday, Nov. 20, 11am-3pm
or
Monday, Nov. 23 through Tuesday, Nov. 24, 11am-3pm

If you have any questions please reach out to nada@charlottepride.org

Name?

E-Mail?

Do you identify as trans, gnc, intersex, nonbinary, or agender?

Yes, I identify this way

No, I do not identify this way but I am getting this box for a family member

No, I do not identify this way and I am picking this box up for myself

Other:

Clear selection

Would you like your self care box delivered to you or would you like to pick it up from Time Out Youth?

I want to pick it up myself at Time Out Youth

I would like it dropped off with me

Clear selection

If you would like your self care box delivered, please let us know what address you would like it dropped off at

What flag colors would you like incorporated to your self care box?

Trans

Intersex

Nonbinary

Agender

Clear selection

If you need your self care box delivered with special instructions (Ex - please leave behind bush, leave in back porch, etc) please let us know here

Is there anything else we need to know?

Submit

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