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Advocates For Youth
Thank you for your interest in becoming a Great American Condom Campaign (GACC) SafeSite. The GACC is a youth-led grassroots movement to make the U.S. a sexually healthy nation. Each year, GACC members give out 1,000,000 Trojan Brand condoms on college campuses across the United States, educate their peers about sexual health, and organize to improve the policies that affect young people's health and lives.

All successful Fall Semester 2010 SafeSite applicants will be notified by October 6th, 2010.

NOTE: This program is for college students in the United States between the ages of 18 and 29. If you are a college/university staff member who is interested in purchasing discounted condoms, please visit trojanprofessional.com.

Have questions? Please email julia@advocatesforyouth.org.


First Name:
Middle Initial:
Last Name:
Birthday (mm/dd/yyyy):
Email address:
Phone Number:

A phone number is necessary for shipping condoms.
We will not share it with other businesses.
Gender:
Ethnicity:
College/University:
Other:

(please write out the full name of your school)

Where is your school located?
City:
State:
Year in School:
Freshman Sophomore Junior
Senior Graduate Student

I live on/off campus

On campus Off campus

If you live on campus or in university housing, what is the name of your dorm/building?
 
How many students live in your building?
 

What is your shipping address? This is where your box of condoms will be shipped. Usually someone has to sign for it, so make sure it is an address where that can happen.
It CANNOT be a P.O. Box!

Address Line 1:

Address Line 2:
City:
State:
Zip:

How many undergraduate students does your campus have?
 
0-2,500 2,500-5,000 5,000-10,000
10,000-20,000 20,000 and up
Most students:
live on campus live on/near campus commute
Is your school:
private public

Are you a residential advisor?

Yes   No

Are you a member of any organizations on campus? If so, what organizations?

Does your college/university have a policy regarding condoms? If so, please describe.

Please mark which of the following is true. Select all that apply.
 
Students can get free condoms from my university (RA, health center, etc.)
Students can get free condoms from a student organization at my university.
Condoms are not distributed on my campus.
Condoms are not allowed on my campus.
I don't know.
Other (explain):

How do most students at your school get condoms? Select all that apply.
 
Health center
Residential Advisor
Student organization
Campus store
Co-Op
Off campus
Don't know
Other:

The Great American Condom Campaign is a product of Advocates for Youth's Youth Activist Network. As a part of the GACC, each accepted SafeSite will receive a box of 500 condoms. Please describe how you plan to distribute all 500 condoms in order to reach the greatest number of people:

How many people do you plan on reaching through your distribution effort?

Are you currently involved in any advocacy efforts around sexual health or other social justice issues? If so, what are you working on?

Why do you want to be a SafeSite?

How did you hear about the Great American Condom Campaign?
 
I was a SafeSite in the past
Advocates for Youth
Friend
Facebook
Other (if website, please specify which website):

If you were a SafeSite in the past, please tell us when you participated. Check all that apply:
 
Fall 2008
Spring 2009
Fall 2009
Spring 2010

Are you willing to be interviewed by the media?
Yes.
Yes, but I don't want my name used.
No thank you.

Advocates For Youth/Great American Condom Campaign Liability Waiver

If selected as a GACC SafeSite, I, (full name) confirm that I:
  
Will distribute all 500 condoms within a school year.
  
Will complete the GACC End-of-the-Semester Survey to report back on my
distribution efforts.
  
Am between the ages of 18 and 29.
  Understand that it is my responsibility to find out my school's policy on condom distribution.

Therefore, I, (full name), understand that I am fully responsible for my decision to distribute condoms on my campus and recognize that Advocates for Youth and the Great American Condom Campaign are not responsible for any administrative action taken by the school against me for my efforts to distribute condoms on my campus. I hereby release Advocates for Youth and the Great American Condom Campaign from any and all liability, responsibility, or any action the school or other administrative body may take as a result of my participation in the campaign.
 



Before you click Continue, please double check your contact information including: name, email address, phone number and address.