Join our Team!

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First Last
Phone*
Email*
Newsletter Sign Up
- Subscribe me to HELP Center's monthly newsletter & program updates
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Street Address Address Line 2 City State ZIP Code
When was the date of your loss?*
Briefly describe why you want to join this group.*
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92701

Name*
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Phone*
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Street Address Address Line 2 City State ZIP Code
Briefly describe why you want to join this group.*
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76700

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We guarantee 100% privacy. Your information will not be shared.
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Briefly describe why you are seeking counseling.*
All information that you provide us will be confidential as required by state and federal law.
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13092

Name*
First Last
Phone*
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Address*
Street Address Address Line 2 City State ZIP Code
Briefly describe why you want to join this group.*
All information that you provide us will be confidential as required by state and federal law.
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7584

Condom of the Month Club - Change of Address Request

Name*
First Last
Email
Old Address*
Street Address City State / Province / Region ZIP / Postal Code
New Address*
You must live in the DFW area to be eligible for this program.

Street Address City State ZIP Code
Phone*
All change of address requests will be voice verified.
Email
This field is for validation purposes and should be left unchanged.

1550

Condom of the Month Club - Cancelation Request

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
All cancelation requests will be voice verified.
Email*
We're sorry to see you go. Please help us improve our service by letting us know why you decided to cancel.*
Your responses will be kept confidential and will not be shared with any other party. Responses will only be used to help improve HELP's free Condom of the Month Club service.
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Please describe your reason.
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59283

Join the Condom of the Month Club!

Name*
First Last
Address*
*You must live in the state of Texas in the DFW area to be eligible for this program.

Street Address Address Line 2 City State: Texas Only ZIP Code
Phone*
All online applications will be voice verified.
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Email Newsletter Opt-in
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I agree to the privacy policy.
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77262

Client Care Specialist – Bilingual