Condom Distribution Order Form

The York Region Public Health, Sexual Health Clinics Condom Distribution Program provides condoms at no cost to non-profit community organizations that provide direct service to clients at elevated risk for unintended pregnancy and sexually transmitted infections.

If your organization would like to order condoms to distribute to your clients, please complete and submit this form. Once received, the Sexual Health Clinics Program will consider the request and will contact your agency using the details provided on this form. Information provided on the order form may also be used for program planning and evaluation purposes.

Notice of Collection

This information is being collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c.H.7 for the purpose of Public Health program administration and statistical purposes. Information will be collected, used, and disclosed in accordance with the Municipal Freedom of Information and Protection of Privacy Act, RSO 1990, c. M.56. Any questions regarding this collection, use, or disclosure may be directed to the sexual health program manager, located at 17150 Yonge Street, Newmarket, Ontario, L3Y 8V3, by email at @email

Distribute the condoms at no cost to the public within York Region

Distribute the condoms only to clients of the organization If the organization wishes to distribute the condoms beyond its clientele, it will obtain the agreement of the Sexual Health Clinics Condom Distribution Program

Include printed condom instructions when distributing condoms

Store condoms in a cool, dry place away from direct sunlight

Monitor expiration dates and not distribute condoms close to or past expiration dates

Acknowledge receipt of the condoms from the Regional Municipality of York, Public Health

Display sign and keep condoms visible and accessible to clients

Name of Agency

Please provide a brief description (1-3 sentences) of your services and client population.