Free Condom Request

1. Please provide the following information:

First Name: *

Last Name: *

Email: *

Street 1: *

Street 2:

City: *

State / Province: *

ZIP / Postal Code

Phone Number: *

Yes, I would like to receive e-mail from Planned Parenthood of the Pacific Southwest.

Yes, I would like to receive postal mail from Planned Parenthood of the Pacific Southwest.

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2. Affiliated Organization / Organización con la que está afiliado: *

3. School District (if applicable) / Distrito Escolar (si aplica):

4. Event Description / Descripción del Evento: *

5. Event date / Fecha del Evento: *

6. Is this request a recurring event? / ¿Este evento es recurrente?

7. Requested Quantity (maximum of 100): *

8. Population to receive condoms / Población que recibirá los condones: *

9. Do you agree not to manipulate or alter the packaging or product in any way without explicit written consent? / ¿Está de acuerdo en no alterar el empaque o el producto sin tener permiso por escrito? *

10. Do you agree not to resell the condoms we donate to you? / ¿Está de acuerdo en no re-vender los condones que le hemos donado? *

11. Can you pick up the donation at our administrative offices in San Diego, Riverside, or Coachella? / ¿Puede recoger la donación en nuestras oficinas administrativas en San Diego, Riverside, o Coachella? *

Special accommodations can be made for Imperial County requests. / Se pueden hacer arreglos especiales para las solicitudes que vengan del Condado de Imperial.

12. Would you like a supply of our services brochure? / ¿Desea recibir folleteria acerca de nuestros servicios?

13. If yes, how many in English? / Si contestó SI, cantidad en Inglés (max 50):

14. How many in Spanish? / Cantidad en Español (max 50):

15. Check here if you are interested in our community education or professional trainings. / Marque aquí si está interesado en nuestros entrenamientos educativos o profesionales.

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FIRST DAY OF YOUR LAST PERIOD

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