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Spring 2017 Great American Condom Campaign

Spring Semester 2017 Applications

The Great American Condom Campaign is a youth-led grassroots movement to make the U.S. a sexually healthy nation. Each year, GACC members give out 1,200,000 Trojan Brand condoms on college campuses across the United States, educate their peers about sexual health, and organize to improve the policies that affect young people's health and lives.

PLEASE APPLY BELOW. Applications will close by midnight, January 11th, 2017. All successful Spring Semester 2017 SafeSite applicants will be notified by January 16th, 2017.

The program is for college students in the United States between the ages of 18 and 29. If you are a college/university staff member who is interested in purchasing discounted condoms, please visit trojanprofessional.com.

Have questions? Please email Amber J. Phillips- Senior Manager, Youth Leadership and Mobilization at AmberP@advocatesforyouth.org.

Name * First Last
Birth Date * MM / DD / YYYY
Email Address *
Cell Phone Number * ### - ### - ####
A phone number is needed for shipping condoms. By providing your cell phone number, you agree to receive calls and texts to that number regarding Advocates for Youth.
Gender *
Sexual Orientation *
Race/Ethnicity *
SCHOOL NAME - IMPORTANT: Fill in the COMPLETE NAME of your college/university (e.g., University of California–San Francisco, State University of New York-Binghamton) *

Please type in the FULL NAME of your school -- NO abbreviations.
Select School Type (check all that apply) *
Public Private Technical/Vocational Community College Historically Black College/University (HBCU) Tribal College Hispanic Serving Institution Asian American and Native American Pacific Islander-Serving Institution (AANAPISI)
In which CITY is your school located? *
In which STATE is your school located? *
Year in School *
Do you live ON or OFF campus? *
ON campus OFF campus
IMPORTANT: Condoms will ship in early FEBRUARY. What will your SHIPPING address be at that time? It CANNOT be a P.O. Box! *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

If you live ON campus, please refer to your campus' guidelines for receiving packages/boxes.
How many undergraduates does your campus have? *
Most of my fellow students: *
Live ON campus Live NEAR campus Commute
Are you a residential advisor? *
Yes No
Does your college/university have a policy regarding condoms? If so, please describe. *
Please mark which of the following statements are true. Check all that apply: *
Students can get free condoms from my university (Resident Assistant, health center, etc.). Students can get free condoms from a student organization at my university. Condoms are not distributed on my campus. Condoms are not allowed on my campus. I don't know -- I'm not sure what my school's condom distribution policies are. Other
You selected "Other." Please explain more about your school's condom distribution policies.
The Great American Condom Campaign is an initiative of Advocates for Youth's Youth Activist Network. As part of the GACC, each accepted SafeSite will receive a box of 500 condoms. Please describe how you plan to distribute ALL 500 condoms in order to reach the greatest number of people: *
Why do you want to be a GACC SafeSite? *
Are you a member of any organizations on campus? If so, what organizations? *
Are you currently involved in any advocacy efforts around sexual health or other social justice issues? If so, what are you working on? *
Would you be interested in helping to educate your friends, register voters, and participate in voter pledge drives as part of your condom distribution efforts? *
Yes No
Do you have any experience in civic engagement efforts related to voting such as registering voters, voter pledge drives, educating peers on voting, and/or GOTV? If so, please explain. *
How did you hear about the Great American Condom Campaign? *
I was a SafeSite in the past. Advocates for Youth Friend Facebook Reddit Other
You selected "Other." Please explain more about how you heard about the Great American Condom Campaign. (If applicable, list all websites and website addresses below.)
I would be interested in receiving more information about organizing & conducting campus activities to: *
End LGBT bullying and harrasment on my campus and in my community Advocate for comprehesive sexual health education Improve birth control access and affortability on my campus and in my community Ensure access to safe and legal abortion services Increase HIV testing opportunities on my campus None of the above.
When were you a SafeSite in the past? Check all that apply:
Spring 2012 Fall 2012 Spring 2013 Fall 2013 Spring 2014 Fall 2014 Spring 2015 Fall 2015 Spring 2016 Fall 2016
Are you willing to be interviewed by the media? *
Yes No
ADVOCATES FOR YOUTH/GREAT AMERICAN CONDOM CAMPAIGN LIABILITY WAIVER

YOUR APPLICATION IS NOT COMPLETE UNTIL YOU CHECK AND FILL IN ALL OF THE MANDATORY FIELDS BELOW.

If selected as a GACC SafeSite, I confirm that I:
#1 *
Will distribute all 500 condoms within a school year.
#2 *
Will complete the GACC End-of-Semester SafeSite Survey to report back on my distribution efforts.
#3 *
Am between the ages of 18 and 29.
#4 *
Am enrolled in a college or university.
#5 *
Am NOT applying for someone else.
#6 *
Understand that it is my responsibility to find out and abide by my school's policy on condom distribution.
I acknowledge ALL of the requirements above, and understand that I am fully responsible for my decision to distribute condoms on my campus and recognize that Advocates for Youth and the Great American Condom Campaign are not responsible for any administrative action taken by the school against me for my efforts to distribute condoms on my campus. I hereby release Advocates for Youth and the Great American Condom Campaign from any and all liability, responsibility, or any action that the school or any other administrative body may take as a result of my participation in the campaign.

[Enter your FULL NAME below to agree with this waiver:] *
Do Not Fill This Out

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ADVOCATES FOR YOUTH/GREAT AMERICAN CONDOM CAMPAIGN LIABILITY WAIVER

If selected as a GACC SafeSite, I confirm that I: