Menstrual Freedom Form — Support Network for Indigenous Women and Women of Color

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? *

How did you find out about this service? *

Please confirm you are located in Victoria, BC *

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