MSM Symposium Registration

Georgia on Mind/Taking Control

2014 MSM Symposium
September 25-26, 2014
The Loudermilk Center
40 Courtland Street Northeast
Atlanta, GA 30303

What is Stigma? How does it impact Gay Men? What role does stigma play in the transmission of STIs like HIV and Syphilis? Join us as we “Peel back the layers” of stigma to reduce STI rates among gay men in Georgia at the 3rd Annual Men who have sex with Men (MSM) Symposium. The purpose of the MSM Symposium is to create a face to face forum for MSM and Health Care Providers to meet and discuss health issues pertaining to the MSM Community. It is also an opportunity to bring together men from all walks of life, introducing them to topics and information that will enlighten and encourage growth.

Reception: Thursday, September 25, 2014
6:00pm- 9:00pm

Symposium: September 26, 2014
Time: 8:00am -4:00pm

Contact: John Malone at john.malone@dph.ga.gov or Leonardo Parker at leonardo.parker@dph.ga.gov

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* 1. Please provide the following background information:

Name:

Title/Position:

Organization Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Degree (i.e. MD,BS,RN, etc.):

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* 2. Race (Please check that which applies)

African American

White/Caucasian

Asian

Native American

Pacific Islander

Other (please specify)

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* 3. Ethnicity (Check that which applies)

Hispanic

Non-Hispanic

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* 4. Age (Check that which applies)

- 20

21-30

31-40

41-50

50+

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* 5. Gender

Male

Transgender(FtM)

Transgender(MtF)

Female

Other (please specify)

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* 6. Sexual Orientation (Check that which applies)

Bisexual

Heterosexual

Homosexual

Other (please specify)

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* 7. What is your geographic location?

Metro Atlanta

Central Georgia

Northwest Georgia

Northeast Georgia

Southwest Georgia

Southeast Georgia

Other (please specify)

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* 8. Do you currently provide services in the HIV/STD prevention field?

Yes (If yes, please describe the capacity in the comment field)

Other (please specify)

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* 9. How long have you worked/volunteered in HIV/STD Prevention

Less than a year

1-2 Years

2-4 Years

5-7 Years

Over 10 years

Consumer

Other (please specify)

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* 10. I am interested in the following topics (Check all that apply)

Health Related Issues

Spirituality

Transgender Community

Social Media & Dating

The National HIV/AIDS Strategy

HIV Care Services (Medicare and Medicaid)

STDs

Disease Management

Partner Services

Other (please specify)

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* 11. I plan to attend:

Just the Reception

Just the Symposium

Both the Reception & Symposium