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):

  Yes No
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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