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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
disregard this