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Condom Program

Full Name

Mailing Address

Age Range


Sex at Birth

Current Gender

Who do you have sex with

Have you ever injected drugs?

HIV Status

If you are HIV negative, would you be interested in a medication to prevent HIV (PrEP)?

How would you prefer to be contacted if we have questions about your request?

How did you hear about this program?

The majority of condoms provided by WCHD are the ONE brand. Descriptions are available at: Please note we offer a selection of these condom options that are listed below.


Which safer sex items would you like to try out?

Type(s) of Condom


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