Apply for Period Dignity Subscription | Denbighshire County Council

Before you complete this form.

If you are under the age of 14 you must have consent from your parent or carer. Your views are important, but you cannot give consent to this referral.

The person giving consent is agreeing to the child joining the subscription service for free sanitary products and to you being contacted by the project administration team.

Registration details
Please enter the details of the person receiving the products.
First name
Last name
Date of birth (DD/MM/YYYY)
Email address
Phone number
Address details

Enter your full address where the products will be delivered.

Please enter a Denbighshire postcode and then click the 'Find address' button.

Alternatively, please type in your address below.
Postcode
Address line 1
Address line 2
Address line 3
Address line 4
Address line 5

Subscription
You can choose one of the following:
- Six-month supply of disposable products (tampons and/or pads).
- Reusable period pants – a single delivery of 7 pants.
- Reusable period cup – a single delivery of 1 cup with sterilising pot in an eco bag.
- Reusable pads – a single delivery of 5 reusable day pads and night pads with a bag.
Please choose your subscription package:
DisposableReusable Period PantsReusable Period CupReusable Pads

Disposable products
Package 1: Pad and Applicator Tampon Bundle Subscription (mixed)
- Day Pads include 10 individually wrapped period pads.
- Night Pads include 8 individually wrapped period pads.
- Regular includes 16 individually wrapped Applicator Tampons.
- Super includes 16 individually wrapped Applicator Tampons.
- Panty liners x 20.
Package 2: Pad and Non-applicator Tampon Bundle Subscription (mixed)
- Day Pads include 10 individually wrapped period pads.
- Night Pads include 8 individually wrapped period pads.
- Regular includes 16 individually wrapped non-applicator Tampons.
- Super includes 16 individually wrapped non-applicator Tampons.
- Panty liners x 20.
Package 3: Applicator Tampon Subscription
- Regular includes 24 individually wrapped Plant Based Applicator Tampons.
- Super includes 18 individually wrapped Plant Based Applicator Tampons.
- Panty liners x 20.
Package 4: Tampon Subscription
- Regular includes 24 individually wrapped Plant Based non-applicator Tampons.
- Super includes 18 individually wrapped Plant Based non-applicator Tampons.
- Panty liners x 20.
Package 5: Period Pad Subscription
- Day Pads include 20 individually wrapped period pads – regular.
- Night Pads 16 include individually wrapped period pads.
- Panty liners x 20.
Please select:
Package 1: Pad and Applicator Tampon Bundle Subscription (mixed)Package 2: Pad and Non-applicator Tampon Bundle Subscription (mixed)Package 3: Applicator Tampon SubscriptionPackage 4: Tampon SubscriptionPackage 5: Period Pad Subscription

Reusable Pants
What size and style would you like? Details about the size and style of the pants can be found at www.heygirls.co.uk:
- Period pants (external website)
- Period pant sizes (external website)
Please select:
Basic briefMid WaistEssential Bikini

Reusable Pants: Basic Brief
Please select:
Basic brief: SmallBasic brief: MediumBasic brief: Large

Reusable Pants: Mid Waist
Please select:
Mid Waist: XSMid Waist: SmallMid Waist: MediumMid Waist: LargeMid Waist: XLMid Waist: 2XLMid Waist: 3XLMid Waist: 4XL

Reusable Pants: Essential Bikini
Please select:
Essential Bikini: SmallEssential Bikini: MediumEssential Bikini: Large

Reusable Cup

Includes: 1 x small or large period cup and 1 x sterilising pot in an eco bag.
What cup size are you?
SmallLarge

Consent form
How old is the person receiving the products?
Under 14 years oldBetween 14 and 17 years old18 years and over

Consent form: Under 14 years old

If you are under the age of 14 you must have consent from your parent or carer. Your views are important, but you cannot give consent to this referral. The person giving consent is agreeing to the child joining the subscription service for free sanitary products and to you being contacted by the project administration team.
Who is giving consent? Please select:
I am the child's parent or carerI am a professional working with the child and have gained consent from the parent or carer. I am responsible for storing that consent.
Which school does the young person attend?

Consent form: 14 to 17 years old

If you are between the ages of 14 and 17 and in education you can consent to your own referral. You are consenting to joining the subscription service for free sanitary products and to being contacted by the project administration team.
Who is giving consent? Please select:
I am the young person's parent or carerI am a professional working with the young person and have gained consent from the parent, carer or young person. I am responsible for storing that consentI am the young person and give consent for this referral
Which school or college does the young person attend?

Consent form: 18 years and over
You will need to agree to the following:
1. Joining the subscription service for free sanitary products and to being contacted by the project administration team.
2. Be aged 18 or over
3. Live in Denbighshire in a low-income household*
* For the period dignity subscription scheme, these is no definition or threshold for a low-income household. This will not be means-tested or checked, it is a self-declaration by each person subscribing.
Please select:
I agree to and confirm that the above three conditions are correct.I do not agree to all three of the conditions. I understand that my application will not be processed.

Equal opportunities

We have to collect the following information, but it does not impact on your application.
Are you a primary carer (including young carers)?
Yes - I am the main carer for a child or children who are under 18Yes - I am the main carer for a disabled adult who is 18 or olderYes - I am the main carer for an older person or people over the age of 65No - I am not a primary carerPrefer not to say
Do you consider yourself to be a disabled person because of the barriers which prevent you from participating fully in all areas of life?
NoYesPrefer not to say

Ethnic Group

If you are 16 or under, you may want to speak to an adult about this question before you answer it.

We need to ask about your ethnic origin for monitoring purposes, but this will not form part of your application.
What is your ethnic group? Choose one option that best describes your ethnic group or background.
WhiteMixed/Multiple ethnic groupsAsian/Asian BritishBlack/African/Caribbean/Black BritishOther ethnic group

Ethnic Group: White
Choose one option that best describes your ethnic group or background.
White - Welsh / English / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy, Romy or Traveller

Ethnic Group: Mixed / Multiple Ethnic Groups
Choose one option that best describes your ethnic group or background.
Mixed / Multiple ethnic groups - White and Black CaribbeanMixed / Multiple ethnic groups - White and Black AfricanMixed / Multiple ethnic groups - White and Asian

Ethnic Group: Asian/Asian British
Choose one option that best describes your ethnic group or background.
Asian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - Chinese

Ethnic Group: Black/African/Caribbean/Black British
Choose one option that best describes your ethnic group or background.
Black/African/Caribbean/Black British - AfricanBlack/African/Caribbean/Black British - Caribbean

Ethnic Group: Other Ethnic Group
Other ethnic group (please specify):

How did you hear about the Period Dignity scheme?
How did you hear about the Period Dignity scheme?
Family memberFoodbank referralFriendSchool or CollegeSocial mediaOtherOther