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. *

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. *

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
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
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
Should be Empty:

Join the Condom Club!

Club Preferences

Contact Info

Demographics