College Outreach Application Form

Free Reminder Kits are limited in quantity. Applications received by 7/1 will be given preference. Applications received after 7/1 will be considered as quantities last. Reminder Kits will be shipped on or around 8/15. Only US Based Colleges/Universities will be considered.
Full Name:

First NameLast Name
College/University:
Job Title/Department:
Address: (College Outreach Program can only serve US based colleges/universities)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
E-mail:
Breifly describe your breast health programming:
How will the FREE Reminder Kit materials would be used?
Would you like a Donation Box included in your Reminder Kit?
(NOTE: The standard Reminder Kit includes a Donation Box in the event you are able to collect donations to help support our campaign. If you are not able to use the Donation Box, please answer NO to this question and we will remove the Donation Box from the materials we sent. If you are able to collect donations as part of your outreach/tabling efforts please answer YES to this question. Any donation helps continue our campaign.)
Are you interested in purchases additional Reminder Kit materials?
(The supplemental packets are $25 and include 100 Shower Cards & 100 Stickers. If you mark Yes to this question, we will contact you to confirm payment information.)
Approximate date needed:
(Our goal is to send all approved Reminder Kits out by August 15th so they are received in time for fall programming.)
Estimated # of students served by program:
Should be Empty:

Free Reminder Kits are limited in quantity. Applications received by 7/1 will be given preference. Applications received after 7/1 will be considered as quantities last. Reminder Kits will be shipped on or around 8/15. Only US Based Colleges/Universities will be considered.