Community Request Form

Please email completed form to

Requests will be confirmed on a first come, first served basis and availability of materials.

Today’s date:

Contact information –

Organization making request:

Email:

Phone:

Please complete this section if you are

ONLY requesting educational materials

Komen North Texas is happy to provide community members with breast health information, but due to budget constraints, we are only able to provide $25 worth of educational materials for each individual/organization. We welcome any donations to help cover the costs of materials. We encourage everyone to visit where you can purchase larger quantities or download certain items for free.

Once your request has been approved, you will need to schedule a pick-up date/time to obtain your materials. If your materials have not been picked-up 3 days after the arranged date, they will be returned to stock.

For a complete description of the materials, please visit and click on “Educational Materials.” Many items are available for free download.

Educational Materials Request only
Requested Quantity / Educational Material / Maximum
Quantity
Breast Self-Awareness Shower cards
  • Available for general audiences, African American or in Spanish. Please designate preference.
/ 45 total
Breast Self-Awareness Large print cards
  • Available for general audiences or in Spanish. Please designate preference.
/ 10 total
Breast Health: Learn the Facts
  • Available for general audiences only.
/ 15 total
Men Can Get Breast Cancer
  • Available for general audiences or in Spanish. Please designate preference.
/ 5 total
Co-Survivors: How to help those you care about cope with breast cancer / 15 total
Take Action bookmarker
  • Available for general audiences or African American. Please designate preference.
/ 20 total
If you have a specific request for information, please check appropriate boxes:
Young women Bilingual Other: ______
Older women Male audience

Is this a “Worship in Pink” request? YES NO

If yes, please provide contact information:

Organization name:
Address:
City, Zip:
Telephone:
Website: