Request edit access
COVID-19 Menstrual Product Needs Survey (YEG)
If you are within the Greater Edmonton Area and are unable to access menstrual products due to COVID-19 restrictions and/or financial barriers, please fill out this form to request products from us.

Please be sure that you have correctly entered your contact information and address, and if you live in an apartment, please provide your suite number.
Sign in to Google to save your progress. Learn more
Name *
Phone Number (Primary contact info) *
Email (Backup contact info)
What is your household's COVID-19 status? *
Address (If you live in an apartment, please list your suite number and/or buzzer code.) *
How many people in your house menstruate? *
What are your product needs? Please keep in mind, we will only be able to provide 1 month worth of products for each menstruator in the household. *
Anything else we should know? (Preferred brands, brands you cannot have, etc.)
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy