1. Organization Information

  • Please use the form below to request your At-Home Rapid COVID-19 Antigen Tests and PPE.
  • Please submit requests for antigen tests or PPE on an as-needed basis but no more than once a week per address.
  • Shipments are sent out once a week but can take up to 3 weeks for delivery and are dependent on available inventory.
  • You will be receiving an email from us with additional information and an estimated delivery date.
  • If you require PPE, please fill out the PPE section at the end of the form.

Question Title

* 1. Please enter your school/program name.

Question Title

* 2. Non-profit or For-profit Organization?

Question Title

* 3. Choose your school/program type.

Question Title

* 5. Enter your school/program's street address for delivery. Please note the address must be located in Los Angeles County and cannot be a P.O. Box.
Example: 200 N Spring St

Question Title

* 6. Enter your school/program's unit or suite number.
Enter "N/A" if not applicable.

Question Title

* 7. Enter your school/program's City.

Question Title

* 8. Enter your school/program's 5 digit zip code.

 
12% of survey complete.

T