Turning the Tide Together for US Hispanics: Rebuilding our HIV Prevention Toolbox - January 23, 2013

Turning the Tide Together for US Hispanic Communities!

 
Welcome! Thank you for your interest in attending Turning the Tide Together for US Hispanic Communities! Please complete the following registration form to ensure a place at the event.
1. Salutation
*
2. First Name
*
3. Last Name
*
4. Email Address

Note: Please provide an accurate email address. This is the delivery method of your registration confirmation, and any other information regarding the event.
*
5. What is your work affiliation? Check all that apply.
*
6. Place of employment
7. Work Address
*
8. City
*
9. State
10. Zip
11. Work Phone Number
12. What is your agency or program Facebook username, if applicable?
13. What is your agency or program Twitter username, if applicable?
14. Gender
15. Race / Ethnicity
16. Sexual Orientation
*
17. Primary language
18. Highest level of education
19. When it comes to priority population serviced by your agency/group, do you currently serve the Latino population?
20. Needs (we will address all needs to the best of our ability):
YesNo
Wheelchair accessibility?
Do you have any special needs?
*
21. How did you hear about this event? (check all that apply)
22. What are you expectations for the event?
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