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!

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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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Email *
Name *
Date of birth *
Home phone number
Cell phone number
Preferred method of contact *
Physical address *
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) *
Average duration of period *
Allergies (latex, scents, synthetic fabric, etc) *
Desired pickup location *
Who referred you to the PAD Center? If you were referred by a referring partner, please select 'other' and share their name. *
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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