COVID-19 Menstrual Product Needs Survey (YEG)

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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.

Name *

Phone Number (Primary contact info) *

Email (Backup contact info)

What is your household's COVID-19 status? *

Tested Positive

Tested Negative

Awaiting test results

Recommended Quarantine (From 811 or a medical professional)

Self Quarantine

Currently "healthy"

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. *

Liners

Pads - Regular

Pads - Super

Pads - Overnight

Tampons - Regular

Tampons - Super

Tampons - Super Plus

Wipes

Other:

Required

Anything else we should know? (Preferred brands, brands you cannot have, etc.)

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