PAD Center Enrollment Form

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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 padcenterva@jrleaguelynchburg.org!

HIPAA Disclaimer:

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.

Email *

BASIC INFO

Name *

Date of birth *

YYYY

Home phone number

Cell phone number

Preferred method of contact *

Home Phone

Cell Phone

Physical address *

Mailing address (if different from above)

Type of residence (house, apartment, shelter, etc) *

Number of people in household *

Average monthly income *

PERIOD INFO

Feminine hygiene product preference (not guaranteed) *

Tampons

Pads

Combination of tampons and pads

Other:

Average duration of period *

Allergies (latex, scents, synthetic fabric, etc) *

Desired pickup location *

Bedford Health Center

Community Access Network, 5th St

CVCC, Community Connections

Johnson Health Center, Lynchburg

Johnson Health Center, Madison Heights

Johnson Health Center, Rustburg

Lynchburg Health Department

Park View Community Mission

YWCA Town Center, Church St

Miller Home for Girls (residents only)

Other:

FINAL QUESTIONS

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

Other:

Are there any other members of your household who would benefit from our services? *

Yes

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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