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CA Condom Request Form
Please fill out the information below to request up to 100 condoms.
Please note, these must be used for educational or sexual wellness purposes only. You can come to the University Health Center Medication Clinic to pick them up after requesting.
For any questions, please call the University Health Center at 660-543-4770.
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CA Name
*
Please provide your first and last name
Your answer
CA 700#
*
Your answer
Your Contact Phone Number
*
Your phone number may be used to contact you regarding your request.
Your answer
Residence Hall, Organization or Class
*
Your answer
Purpose
*
Please note, these must be used for educational or sexual wellness purposes only.
Your answer
Number and Types of Condoms Requested
*
You may request up to 100 total. Types available: regular male latex, large male latex, regular male latex free, and dental dams. Number and types provided may vary depending on health center's supply.
Your answer
Verification
*
Enter your name and today's date; by doing so you are verifying that everything you entered above is correct.
Your answer
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