Join Our Condom Club

Join the Condom Club!

Thank you for your interest in joining 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 every other month. *

Yes No
Condom Preference (Select ONE option): *

Premium condoms XL condoms Combination of Premium and XL condoms Internal (FEMALE) condoms
I would like to receive 25 foil packets of lube every other month. *

Yes No lube desired
Contact Info
First and Last Name *

First Name Last Name
Preferred Language *

English Spanish
E-mail *
Phone Number *

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

Yes No
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Demographics
Gender *

Male Female Trans Woman Trans Man Transgender (unspecified) Gender-Fluid Non-Binary
Sexual Identity *

Straight or Heterosexual Gay Bisexual Lesbian Pansexual Asexual Two-Spirited
Do you identify as Hispanic or Latino? *

Yes No
Race (Check all that apply)

American Indian / Alaskan Native Asian Black / African American Nativ Hawaiian / Pacific Islander White / Caucasian
How long has it been since your last HIV test? *

Less than 1 month 2-6 months 7-12 months More than 12 months I 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 sex Vaginal or anal sex with a female Vaginal or anal sex with a transgender person Vaginal or anal sex with a male
Are you interested in any of the following? (Select ALL that apply) *

learning more about PrEP starting PrEP help getting to a PrEP appointment testing for HIV testing for HIV at home testing for STDs (like syphilis or chlamydia) testing for Hepatitis C learning more about resources for someone with HIV help getting to HIV medical care or support services
How did you learn about EAC's Condom Club? *

Google or Online Search Radio or Podcast Hulu Ad Our Website Facebook Ad or Post Dating App Special Event Brochure or Printed Material Referred by a friend Referred by a staff member at EAC Previously requested condoms/lube
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Join the Condom Club!

Club Preferences

Contact Info

Demographics