Menstrual Freedom

First Name*

Last Name*

Pronouns*

Phone*

Email*

Age*

Street*

City*

Province*

How do you self identify?*

What is your marital status?*

How many dependants do you have in your home?*

Are you considered as low-income ?*

How did you find out about this service?*

Please confirm you are located in Victoria, BC*

Please upload your proof of income*

File(s) size limit is 20MB.

SNIWWOC Pipeline

Enrolled in Menstrual Program

I hereby read and understand all the Menstrual Freedom Policies and conditions for applying for this program.

Please accept this