Student Sample Kit Request Form
In order to qualify for FREE Student Sample Kits, there are two requirements. The Instructor must agree to play a short video about responsible menstrual hygiene disposal for the students and complete a short feedback survey afterward.
(Agreement on Page 2)
Email address *
Name of School or School District *
Your answer
Your Name *
Your answer
Job Title *
Your answer
Phone Number (Direct Please) *
Your answer
Shipping Address (Please include: Street Address, City, State and Zip Code) *
Your answer
How many student sample kits do you need? *
Your answer
What date do you need the kits? (Must order at least 3 weeks in advance) *
MM
/
DD
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YYYY
How do you prefer we contact you? *
How did you hear about us? *
Your answer
What intrigues you the most about participating in our supplemental puberty education program? *
Required
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