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.
Street Number and Street Name
Black or African-American
American Indian or Alaskan Native
Native Hawaiian or other Pacific islander
From multiple races
What is your current gender identity?
Trans male/Trans man
Trans female/Trans woman
Do you think of yourself as?
Gay or lesbian
Please provide accurate information below to ensure the delivery of the signed copies of the document.
Legal Full Name (as you would sign):
Valid Email Address: