SisterReach Safe Sex Kit Request Form
In times like these, when you stay ready, you don't have to get ready.

Please complete this form below to request your FREE Safe Sex Kit. Options include Male Condoms, Internal Condoms, Dental Dams, Emergency Contraception, Lube, and Masks. Please note that we are only processing Memphis Safe Sex Kit requests at this time. Please note: We have limited stock for out of state requests due to budgetary restraints; however, we will fill as many as possible.

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First Name *
Last Name *
Email Address *
Mailing Address 1 *
Apartment/Suite Number
City *
State *
Zip Code *
Age *
Gender *
Self-identified Sexual Orientation *
Race/Ethnicity *
Please select what item(s) you need: *
Required
Weight (If ordering Emergency Contraceptives. Some orders may require more than one Emergency Contraceptive in order for them to work effectively)
Self-identified HIV Status *
Disclaimer
We will honor every Memphis request in full until items run out. Items are on a first-come-first-served basis. *If under 18, please be aware that we are sometimes receiving calls from the adult(s) at your residence. We want to continue serving you and not pose any issues for you with your parent or guardian though we WILL honor your order. Please take this into consideration and let your parent or guardian know (if safe to do so) that this type of order is coming.
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