Registration Form/Pre-Test Assessment

1. Demographics

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* 1. Enter Your Email Address (*please take note of the email used because it will be needed for activities going forward; if you do not have an email address, please call 601-576-7723 to receive an unique ID)

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* 2. Contact Information

Name

Phone Number

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* 3. Which one of the following you can be identified? Please select all that apply.

Parent

Grandparent

Guardian

Self

Other Category (please specify)

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* 4. Select Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

Another Race/Ethnicity (please specify)

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* 5. What is your county of residence?

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* 6. What is your gender?

Female

Male

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* 7. What age range are you in?

15-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61+

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* 8. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Master degree

Ph.D/Doctorates

Other (please specify)

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* 9. Are you currently employed?

Yes

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* 10. Are you currently enrolled as a student?

Yes

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* 11. Have you had an STD/HIV training before?

Yes