Condom Subscription
Are you a Baltimore City resident?
*
Yes
No
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Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please select to:
*
Include name on shipping
Leave name off of shipping
Pick one:
*
I would like to receive health department updates and upcoming events
I would not like to receive health department updates and upcoming events
What is your gender?
*
Please Select
Male
Female
Transgender Male
Transgender Female
What is your ethnicity? Please select all that apply:
Black
White
Asian / Pacific Islander
Latino / Hispanic
How old are you?
Under 18
18-30
31-40
41-50
51-60
Over 60
How often do you use a condom during vaginal sex?
How often do you use a condom during oral sex?
How often do you use a condom for anal sex ?
Please check this box if you would to receive non-latex condoms.
Non-latex, please
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I'm sorry, but this program is only available to Baltimore City residents!
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