Contact Information

* 1. First Name:

* 2. Last Name:

* 3. Legal Name* (if different from above):
*note, we will never use this to identify you, this is simply for legal reasons and in case of emergency. This information will be kept in confidence by select staff at ARCH and will not be available to other peers, the community, or anyone outside of the ARCH program. 

* 4. Pronouns:

* 5. Address:

* 6. City:

* 7. Province:

* 8. Postal Code:

* 9. Home Phone:

* 10. Cell Phone:

* 11. Email:

* 12. Discretion* required?
*select "yes" if receiving information with ARCH branding or specifying the nature of the work you're doing with us could be potentially harmful, dangerous or otherwise unwelcome for you. This includes if other members of your household or those who share your phone number are unaware of your HIV status, trans/queer status, or of you having any kind of involvement with the organization. 

  Do not contact me through this method Discretion needed Some discretion needed OK to contact I don't have this type of contact method
For mailing to above address (letters, etc.)
For calling Home Phone number
For leaving voicemail messages at Home Phone number
For calling Cell Phone number
For texting Cell Phone number
For leaving voicemail messages at Cell Phone number
For emailing to the above email address

* 13. Emergency Contact Information