Free Condom Request

Condom requests are granted based on availability to those in our service regions. You must be in San Diego, Riverside, or Imperial Counties to receive condom donations.

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.

Keep me logged in.

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. 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? *

9. 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? *

10. 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.

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

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

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

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