Name
*
First Name
Last Name
Do you live in SE or SW Atlanta and within city limits?
*
Yes
No
Are you Black?
*
Yes
No
How many people live in your household?
*
Does anyone in your home or who you have regular contact with have flu-like symptoms?
*
Yes
No
Which package(s) would you like to receive?
*
Select the package(s) you need below:
If you selected Feminine Health Care, how many people in your household need these items?
If you selected Feminine Hygiene Items, which menstrual items would you like?
Please list any other items you need that are not on the list (There is no guarantee these can be provided):
Additional Information
Please include your sizes for any of the above items, or any other additional information that you would like included in your packages (sizes, additional instructions, etc.).
Email
Phone Type (select one):
Cell
Home
Work
Phone
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Would you like to receive regular updates from Community Movement Builders about the organizing and other activities we are doing in the community? (We may call/text/email you with updates)
*
Yes
No