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Sign- Up Sheet & Availability

Sign-up sheet & Availability for our weekly Online Support Group meetings. Current schedule is: every Monday 5pm-6pm
All Information is confidential and data will be used to access grants to fund the Transgender Health and Wellness Center.

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* 1. Date

Date

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* 2. Legal Name

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* 3. Preferred Name

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* 4. Address

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* 5. What is your email address?

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* 6. Would you like to be notified for future events?

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* 7. Which platform do you prefer?

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* 8. What days and times work best for you?

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* 9. Date of Birth

Date

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* 10. Age

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* 11. Race/Ethnicity

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* 12. Ethnicity

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* 13. Religion

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* 14. Sexual Orientation

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* 15. What is your gender identity?

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* 16. What is your HIV status?

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* 17. What is your Hepatitis C status?

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* 18. Have you ever thought of or attempted suicide in the past?

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* 19. Do you smoke cigarettes?

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* 20. Have you ever smoked cigarettes?

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* 21. Do you smoke marijuana?

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* 22. Have you ever smoked marijuana?

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* 23. What is your annual income?

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* 24. What is your current housing status?

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* 25. Please check what services you are seeking at the Transgender Health and Wellness Center.

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* 26. Comments/Suggestions/Inquiries

0 of 26 answered
 

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