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):
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Premium condoms
XL condoms
Combination of Premium and XL condoms
Internal (FEMALE) condoms
I would like to receive 25 foil packets of lube.
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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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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?
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Brochure or Printed Material
Dating App (Grindr, Scruff, Tindr)
Facebook or Instagram
Google or Online Search
Podcast
Referred by friend
Referred by staff at EAC
Special Event
Website - Engaging Arkansas Communities
Website - Arkansas Resource Hub
Submit
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
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