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Take Cover Request Form

"Take Cover" Program

"Take Cover" is a FREE condom and sexual health supply distribution program through the Midland County Department of Public Health (MCDPH). 

To request FREE home delivery of a "Take Cover" kit, complete this confidential request form. 

Upon completion of the request form, a "Take Cover" kit will be discreetly packaged in an unmarked envelope and mailed to your chosen location (within the State of Michigan).


FREE "TAKE COVER" KITS can also be picked up in-person from partnering locations throughout Midland County: 


Take Cover Kit Distribution Sites 
 

Take Cover Map

This question requires a valid email address.
2. Are you a current patient of the Midland County Department of Public Health (MCDPH)? *This question is required.
3. How did you learn about the "Take Cover" program? *This question is required.
4. Check the box by all items you would be interested in receiving. 

*Please note, based on available supply, some options may not be available at the time of request. *This question is required.
5. What Midland County Department of Public Health (MCDPH) programs and services are you familiar with?  Select all that apply:

MCDPH Brochure


 
6. Mailing Address (where "Take Cover" kit will be sent): *This question is required.
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