PPMM Outreach Kits: Request Form (FY24)

PPMM Outreach Kits: Request Form (FY24)

Not-for-profit organizations, schools, government agencies, and community event organizers within Planned Parenthood Mar Monte's (PPMM) 42-county service area can request PPMM Outreach Kits. These kits are designed to be distributed directly to youth and adults, promoting sexual health and education.

Instructions

Complete the form below to request FY24 kits based on the population you aim to serve:

Middle School Kit: 450 Pamphlets
High School & Young Adult Kit: 350 Pamphlets+100 Condoms+100 Lube Packs
Parents & Adults Kit: 600 Pamphlets
Period Kits: 500 tampons/pads + 100 info cards

Delivery Information

Kits are shipped two days a month by our team. Expect to receive your kit within 30 days of submitting this form.

>> Learn more about the kits here!

Note: Requests are fulfilled based on availability and shipped at no cost. The kits may not include all the items or brands pictured. Thank you for your interest in promoting sexual health education within your community!

Contact Information

Organization Name*

Website*

If none, put N/A

Total # of INDIVIDUALS your org serves annually*

Please make your best estimate or use count from the most recent annual report.

PPMM County*

Select from the drop-down or choose 'other' from list and write in

Select

Please write in your organizations county

If you choose 'other' for the county, please write in your organizations county.

Email*

Phone #: (000-000-000)*

This is used in case we have questions about your request.

Phone

Shipping Information

First Name*

Last Name*

Street Address *

City*

State*

Select or enter value

Other States

Select or enter value

Zip Code *

Who Will Receive Kits?

Data requested helps PPMM Education assess the populations reached through kits distributed by community partners.

Please provide % estimates below:

Please choose ONE primary setting where the kits/materials will be distributed.*

Select

AGE group:*

Select the ONE age group representing most individuals you will serve with PPMM Kits.

Select

% of individuals who live at or below 200% of the Federal Poverty Level:*

Schools may provide % of students eligible for Free & Reduced Lunch at your site.

Select or enter value

% who speak a language OTHER than English in their home*

Select or enter value

% identify as AAPI/Asian American*

East Asian, South Asian, Southeast Asian, Pacific Islander or another Asian background.

Select or enter value

% identify as American Indian/NATIVE AMERICAN*

Alaskan Native, other INDIGENOUS

Select or enter value

% identify as BLACK or African American*

Select or enter value

% identify as LATINe/o/a/x or Hispanic*

Select or enter value

% identify as Middle Eastern/North African:*

Select or enter value

% identify as WHITE*

White American, Caucasian

Select or enter value

% identify as MULTI-RACIAL*

Select or enter value

Sex Ed Kits

Please select the kit(s) you'd like to receive:*

Select

The number of outreach items you AGREE to distribute from your kit by 06/30/24.*

This is required for PPMM impact tracking. Kits include:

Middle School & Younger Teen Kit: 300 Pamphlets
High School & Young Adult Kit: 150 Pamphlets+100 Condoms+100 Lube Packs
Parents & Adults Kit: 150 Pamphlets+100 Condoms

Comments or additional requests

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