PCS - COVID19 Testing 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 Name Last Name

What is your phone number? *

Area Code Phone Number

What is your e-mail address?

example@example.com

What is your age? *

How do you identify your gender? *

Female Male Trans Male Trans Female Non-Binary

What is your ethnicity? *

Hispanic or Latino/ Latinx Not Hispanic or Latino/ Latinx Decline to Answer Don't Know

What is your race? *

Black / African American White Alaskan Native Asian Native American Native Hawaiian Pacific Islander Decline to Answer Don't Know

How would you describe your housing situation? *

Stably Housed At risk of being homeless Homeless

Would you prefer to pick these up or have them delivered? *

Pick up Delivery

What is your delivery address? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Would you also like safe sex kits? *

Yes No

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