Donation to benefit your organization directly (US & Canada Only)

Name*

*

Organization Details

If you are an individual please type NA

Telephone*

Email*

What services does your organization offer?

Does your organization engage in street outreach activities?

Yes
No

Is this your organization’s primary activity?

Yes
No

Does your organization have a client intake process?

Are you or your team familiar with menstrual cups?

What items are you requesting for donation? (Tick all that apply)

Model 0
Model 1
Model 2
Demonstration Kits
Educational Materials

How will the DivaCup be distributed?

Does your organization have access to medically trained staff?

(not a requirement for donation)

Does your organization provide toiletries such as soap and menstrual care products

(Please note that the DivaCup has to be cleaned with non-scented, oil free fragrance free soap 2-3 times a day during use)

Are there members of your organization/cause who are willing to receive a (20 min) DivaCup Q&A session over the phone/Zoom with one of our DivaCares team members?

Do those you care for have access to showers/washroom facilities at all times?

Is your organization open to sharing media (pictures, videos, blogs) with DivaCares for the purposes of promoting your initiatives on our social media channels?

Yes
No