PCS - COVID19 Testing Kits

COVID-19 Kits
COVID-19 Kits include: Masks, Reusable Thermometer, Hand Sanitizer
How many COVID-19 kits would you like?*
You can order a maximum of 10 kits using this form. If you need more than 10 please call our office: (708) 589-1300
What is your name?*

First NameLast Name
What is your phone number?*

Area CodePhone Number
What is your e-mail address?
example@example.com
What is your age?*
How do you identify your gender?*

FemaleMaleTrans MaleTrans FemaleNon-Binary
What is your ethnicity?*

Hispanic or Latino/ LatinxNot Hispanic or Latino/ LatinxDecline to AnswerDon't Know
What is your race?*

Black / African AmericanWhiteAlaskan NativeAsianNative AmericanNative HawaiianPacific IslanderDecline to AnswerDon't Know
How would you describe your housing situation?*

Stably HousedAt risk of being homelessHomeless
Would you prefer to pick these up or have them delivered?*

Pick upDelivery
What is your delivery address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you also like safe sex kits?*

YesNo
How many safe sex kits would you like?*
Max 10
You can order a maximum of 10 kits using this form. If you need more than 10 please call our office: (708) 589-1300
Should be Empty:

COVID-19 Kits