[Ingham County] Condom Request Form

Condom Request Form

Fill out this confidential form, and we will mail you free condoms in an unmarked envelope.

At this time, ICHD is only able to mail condoms to addresses within Ingham County or the city of Lansing.

First Name

Last Name

Condoms / Protective Products Requested

Condoms (Regular)

Condoms (XL)

Latex Free Condoms

Dental Dams

Flavored Condoms

Street Number and Street Name

City

Zip Code

Age

Race/Ethnicity

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific islander

From multiple races

What is your current gender identity?

Male

Female

Trans male/Trans man

Trans female/Trans woman

Genderqueer/Gender non-conforming

Do you think of yourself as?

Straight

Gay or lesbian

Bisexual

By checking this box, I am certify that I live Lansing or Ingham County. I am making this request for myself and agree these condoms will be used for personal use between consenting individuals and will not be sold.

I agree