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Sexual Assault Evidence Collection Kit order Form

Date *

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Year Year20212022202320242025

First Name *

Middle Name or Initial

Last Name *

Hospital/Rape Crisis Center/Medical Provider *

Are you a Non-profit 501 (c)(3) Organization? (for educational purposes only) *

YES

NO

Affiliated With * - Select -Abbott House Child Advocacy Center, NormanAllianceHealth DurantAllianceHealth WoodwardArkansas Children's Northwest HospitalAtoka County Medical Center, AtokaBooker's Place Child Advocacy Center - JCMH, AltusCARE Center Child Advocacy Center, Oklahoma CityCARE Cottage Child Advocacy CenterChickasaw Nation Medical Center, AdaChoctaw Nation Health Care Center, TalihinaFort Smith Crisis Intervention Center, ArkansasGrady Memorial Hospital, ChickashaGrayson County SART, TXGreat Plains Regional Medical Center, Elk CityHamilton House Child Safety CenterHELP Advocacy Center SW Oklahoma, LawtonHelp-in-Crisis (Tahlequah, Sallisaw, Wagoner, Stilwell)Hooker Medical ClinicINTEGRIS Hospital - NortheasternINTEGRIS Medical Group - MiamiJackson County Memorial Hospital, AltusJPS Health NetworkKids Space, Muskogee Co. Child Advocacy Ctr., MuskogeeLeFlore Co. Child Advocacy Network, PoteauMcAlester Regional Health Center, McAlesterMcCurtain Co. SANE Program, IdabelMercy Hospital, AdaMercy Hospital, ArdmoreMuscogee (Creek) Nation Medical Center, OkmulgeeNorth Texas Medical Center - Gainesville, TXNorthwest Arkansas Ctr. for Sexual Assault, ArkansasOne Safe Place Family Justice Center/ Unzner Center, ShawneeOU Children's Hospital, Oklahoma CityPC-CARE, McAlesterProject Safe (Adult Program), Shawnee, OKRay of Hope Advocacy Center, BartlesvilleRural Forensic SANE, TalihinaSafe Center, Inc., DuncanSAFE-NOW (Nowata, Osage & Washington counties), BartlesvilleSara's Project Children's Advocacy Center, ArdmoreSTART Child Advocacy Center, SayreStillwater Medical Center, StillwaterSurvivor Resource Network, Ponca CityTexoma Medical CenterThe Family Shelter of Southern OK, MariettaThe Saville Center for Child Advocacy, StillwaterTrail Creek Wellness Hospital, KingfisherTulsa SANE Program (Hillcrest Medical Center), TulsaWeatherford Regional Hospital, WeatherfordWhite Eagle Health Center, Ponca CityWilliam W. Barnes Child Advocacy Ctr., ClaremoreWomen’s Crisis Intervention Center - Fort Smith, ArkansasWomen's Resource Center, NormanYWCA, EnidYWCA, Oklahoma City

Email *

Contact Number *

Street Address *

City *

State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Sexual Assault Kit Quantity -Select Qty-5102040 (1 case)80 (2 cases)120 (3 cases)160 (4 cases)

Drug Facilitated Kit Quantity -Select Qty-510 (1 case)20 (2 cases)

Additional Comments

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