First Name *
Middle Name or Initial
Last Name *
Hospital/Rape Crisis Center/Child Advocacy Center *
- Select - Hospital Rape Crisis Center Child Advocacy Center
Affiliated With *
- Select - Abbott House Child Advocacy Center, Norman Ahni Justice Center AllianceHealth Durant AllianceHealth Woodward Arkansas Children's Northwest Hospital Atoka County Medical Center, Atoka Booker's Place Child Advocacy Center - JCMH, Altus CARE Center Child Advocacy Center, Oklahoma City CARE Cottage Child Advocacy Center Chickasaw Nation Medical Center, Ada Choctaw Nation Health Care Center, Talihina Fort Smith Crisis Intervention Center, Arkansas Grady Memorial Hospital, Chickasha Grayson County SART, TX Great Plains Regional Medical Center, Elk City Hamilton House Child Safety Center HELP Advocacy Center SW Oklahoma, Lawton Help-in-Crisis (Tahlequah, Sallisaw, Wagoner, Stilwell) Hooker Medical Clinic INTEGRIS Hospital - Northeastern INTEGRIS Medical Group - Miami Jackson County Memorial Hospital, Altus JPS Health Network Kids Space, Muskogee Co. Child Advocacy Ctr., Muskogee LeFlore Co. Child Advocacy Network, Poteau McAlester Regional Health Center, McAlester McCurtain Co. SANE Program, Idabel Mercy Hospital, Ada Mercy Hospital, Ardmore Muscogee (Creek) Nation Medical Center, Okmulgee NeoHealth Pediatrics North Texas Medical Center - Gainesville, TX Northwest Arkansas Ctr. for Sexual Assault, Arkansas One Safe Place Family Justice Center/ Unzner Center, Shawnee OU Children's Hospital, Oklahoma City PC-CARE, McAlester Project Safe (Adult Program), Shawnee, OK Ray of Hope Advocacy Center, Bartlesville Rural Forensic SANE, Talihina Safe Center, Inc., Duncan SAFE-NOW (Nowata, Osage & Washington counties), Bartlesville SANE Mobile-Melisa Verdin Sara's Project Children's Advocacy Center, Ardmore START Child Advocacy Center, Sayre Stillwater Medical Center, Stillwater Survivor Resource Network, Ponca City SWMC SANE Program Texoma Medical Center The Family Shelter of Southern OK, Marietta The Saville Center for Child Advocacy, Stillwater Trail Creek Wellness Hospital, Kingfisher Tulsa SANE Program (Hillcrest Medical Center), Tulsa Weatherford Regional Hospital, Weatherford White Eagle Health Center, Ponca City William W. Barnes Child Advocacy Ctr., Claremore Women’s Crisis Intervention Center - Fort Smith, Arkansas Women's Resource Center, Norman YWCA, Enid YWCA, Oklahoma City
Email *
Contact Number *
Street Address *
City *
State *
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Zip Code *
Sexual Assault Kit Quantity
-Select Qty- 5 10 20 40 (1 case) 80 (2 cases) 120 (3 cases) 160 (4 cases)
Drug Facilitated Kit Quantity
-Select Qty- 5 10 (1 case) 20 (2 cases)
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