Hepatitis Leadership Corps Application

Personal Information

Please fill this out using the exact information that is on your license. It will be used to make your flight reservations and must match ID. Date of Birth is required by TSA.

Question Title

* Personal Information

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Date of Birth *

Email Address: *

Mobile Number: *

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* What is your gender?

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* What is your racial origin?

Caucasian

African American

Hispanic

Asian/Pacific Islander

Native American

Other (please specify)

Question Title

* Why do you want to be an advocate for viral hepatitis? (check all that apply)

I am currently living with HCV

I have been cured of HCV

I have a family member with HCV

I have a family member cured of HCV

I am currently living with HBV

I have a family member with HBV

Other (please specify)