Hygiene Kit Request Form

Native American LifeLines is offering our community members hygiene care packages free of charge! If you are interested in a hygiene care package, please fill out this survey and we will ship your items to you in discrete packaging. If you have any questions, please email info@nativelifelines.org.

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* 1. Contact Information

First name *

Last name

Email Address *

Phone Number *

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* 2. Are you affiliated with a federally- or state-recognized tribe?

Yes - I am an enrolled member of a Federally Recognized Tribe

Yes - I am an enrolled member of a State Recognized Tribe

Yes - I am a descendant of a Federally Recognized Tribe but I am not enrolled

Yes - I am a descendant of a State Recognized Tribe but I am not enrolled

No - I am not an enrolled member or descendent of a Federally or State Recognized Tribe

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* 3. If you selected yes, what tribe are you affiliated with?

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* 4. Shipping Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

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* 5. Please select all hygiene items that you would like included in your hygiene care package:

Shampoo

Conditioner

Body Wash

Bar Soap

Lotion

Razors

Shaving Cream

Tampons

Pads

Menstrual Cup

Menstrual Disk

Toothbrush

Toothpaste

Floss

Mouthwash/Oral Rinse

Deodorant

Hygiene Kit Request Form

Question Title

* 1. Contact Information

Question Title

* 2. Are you affiliated with a federally- or state-recognized tribe?

Question Title

* 3. If you selected yes, what tribe are you affiliated with?

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* 4. Shipping Address

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* 5. Please select all hygiene items that you would like included in your hygiene care package:

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* 6. Special delivery requests: