Join Our Condom Club

Join the Condom Club!

Thank you for your interest in our Condom Club! We collect basic information below to be able to send FREE condoms and/or lube directly to you. Your information is always kept confidential according to strict HIPAA guidelines. Supply is based on current stock and available funding.
Club Preferences

NOTE: Condom type and amount may change from month to month and is based on donations received. We will do our best to fill your request whenever possible!
I would like to receive 25 condoms.*

YesNo
Condom Preference (Select ONE option):*

Premium condomsXL condomsCombination of Premium and XL condomsInternal (FEMALE) condoms
I would like to receive 25 foil packets of lube.*

YesNo lube desired
Contact Info
First and Last Name*

First NameLast Name
Preferred Language*

EnglishSpanish
E-mail*
Phone Number*

Area CodePhone Number
Are you able to receive text messages at this phone number?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Demographics
Gender*

MaleFemaleTrans WomanTrans ManTransgender (unspecified)Gender-FluidNon-Binary
Sexual Identity*

Straight or HeterosexualGayBisexualLesbianPansexualAsexualTwo-Spirited
Do you identify as Hispanic or Latino?*

YesNo
Race (Check all that apply)

American Indian / Alaskan NativeAsianBlack / African AmericanNativ Hawaiian / Pacific IslanderWhite / Caucasian
How long has it been since your last HIV test?*

Less than 1 month2-6 months7-12 monthsMore than 12 monthsI have never been tested
Which best describes your use of PrEP (Pre-Exposure Prophylaxis)?*

I do not know about PrEP.I take PrEP sometimes.I take on-demand PrEP around sexual activity.I have heard of PrEP, but never taken it.I take PrEP once a day as perscribed.I was taking PrEP, but am not now.
Sexual activity requiring condoms: (Select ALL that apply)*

Oral sexVaginal or anal sex with a femaleVaginal or anal sex with a transgender personVaginal or anal sex with a male
How did you learn about EAC's Condom Club?*

Brochure or Printed MaterialDating App (Grindr, Scruff, Tindr)Facebook or InstagramGoogle or Online SearchPodcastReferred by friendReferred by staff at EACSpecial EventWebsite - Engaging Arkansas CommunitiesWebsite - Arkansas Resource Hub
Are you interested in any of the following? (Select ALL that apply)*

learning more about PrEPstarting PrEPhelp getting to a PrEP appointmenttesting for HIVtesting for HIV at hometesting for STDs (like syphilis or chlamydia)testing for Hepatitis Clearning more about resources for someone with HIVhelp getting to HIV medical care or support services
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Join the Condom Club!

Club Preferences

Contact Info

Demographics