PAD Center Enrollment Form
Periods can be expensive, but we’re here to help! If you need assistance in getting the feminine hygiene products that you need each month, the PAD Center can provide FREE products for you. To enroll in our free monthly subscription of feminine hygiene products, please fill out the following form. Need assistance or have questions? Email us at
The information contained in this document may contain privileged and confidential information, including information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby noticed that any review, dissemination, distribution, or publication of this document is strictly prohibited.
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Date of birth
Home phone number
Cell phone number
Preferred method of contact
Mailing address (if different from above)
Type of residence (house, apartment, shelter, etc)
Number of people in household
Average monthly income
Feminine hygiene product preference (not guaranteed)
Combination of tampons and pads
Average duration of period
Allergies (latex, scents, synthetic fabric, etc)
Desired pickup location
YWCA Town Center, Church St
Community Access Network, 5th St
Lighthouse Community Center, Church St
Johnson Health Center, Lynchburg
Johnson Health Center, Rustburg
Who referred you to the PAD Center? If you were referred by a referring partner, please select 'other' and share their name.
Self-referred, learned through word of mouth
Self-referred, learned through another PAD Center client
Self-referred, learned through TV/radio/social media
Self-referred, learned through online search
Are there any other members of your household who would benefit from our services?
If yes, who? If you would like to sign them up, please fill out a separate enrollment form.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Junior League of Lynchburg.