Resource Request Form — Health Promotion - a division of Campus Health Services

Resource Request Form

To request resources for your student group/organization, classroom, or residence hall, please fill out and submit the form below. You will be contacted by a Campus Health Health Advocate Leader approximately two business days after submitting your request to confirm your submissions

Questions? Contact Riece Hamilton Program Coordinator, by phone: 502-852-1914 or email our service account.

Today's Date

Year/Month/Day

Person Requesting Resources

Name

E-Mail Address

Phone Number

Organization

Other Position

Resources Choose the materials that you would like to request from the dropdown. Anything with an asterisk (*): 3 maximum; more available upon making a Program Request. Play Well Hot Spot Starter Kit includes external condoms (regular and large), lubricant samples, informational pamphlets, HPV pledge cards, and condom instructions. Play Well Hot Spot Refill: Refill your Play Well Hotspot with a specific number of items. Item number= the amount of HotSpots you are refilling. Each item comes in bags, please request the amount of bags you need for each HotSpot

Item Quantity

Regular size condoms Enter number of bags. (bags of 50)

Large size condoms Enter number of bags. (bags of 30)

Lubricant Enter number of bags. (bags of 25)

Sexual Health Pamphlets Enter number of stacks. (stacks of 10)

Condom Instructions Enter number of stacks. (stacks of 10)

HPV Initiative Cards Enter number of stacks. (stacks of 10)

If Brochures/Educational Materials, what topic would you like these for?

Campus

Belknap
HSC

Location

How will these resources be used?

Date/Time Needed

Year/Month/Day Hour:MinuteAM/PM