Registration Page

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* 1. Name

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* 2. Which program are you registering for?

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* 3. Contact information

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* 4. Preferred mode of contact

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* 5. Can we leave a message via voicemail?

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* 6. What is your age

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* 7. What is your city or town of residence

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* 8. What sex were you assigned at birth

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* 9. Gender identity

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* 10. What are your pronouns?

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* 11. What is your country of origin?

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* 12. What is your primary language?

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* 13. Our programs serve diverse communities. If you identify with one or more of the following communities, please click yes.

- African, Caribbean, or Black
- Living with HIV/AIDS
- Two Spirit, Lesbian, Gay, Bisexual, Transgender, and/or Queer
- Have experience with substance use (past or present)
- Woman (Assigned female at birth or transgender)

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* 14. Where did you hear about us?

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