Turning the Tide Together for US Hispanics: Rebuilding our HIV Prevention Toolbox

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* 4. Email Address

Note: Please provide an accurate email address. This is the delivery method of your registration confirmation, and any other information regarding the event.

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* 5. What is your work affiliation? Check all that apply.

Community Based Organization (CBO)

Grassroots Group

Faith Based Organization

Coalition

Clinic/Hospital

NYU Student

NYU Staff

Other University Student

Other University Staff

Health Department

Centers for Disease Prevention and Control (CDC)

Corporation

Media

Other (please specify)

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* 6. Place of employment

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* 7. Work Address

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* 8. City

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* 9. State

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* 10. Zip

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* 11. Work Phone Number

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* 12. What is your agency or program Facebook username, if applicable?

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* 13. What is your agency or program Twitter username, if applicable?

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* 14. Gender

Male

Female

Transgender (male to female)

Transgender (female to male)

Other (please specify)

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* 15. Race / Ethnicity

African American / Black

Caucasian / White

Hispanic / Latino

Asian / Pacific Islander

Native American

Other (please specify)

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* 16. Sexual Orientation

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* 17. Primary language

English

Spanish

Other (please specify)

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* 18. Highest level of education

Less than 12 years of education

High school / GED

Some college

Associate's degree

Bachelors / Undergraduate degree

Masters / Graduate degree

Ph.D.

Other professional advanced degrees (please specify)

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* 19. When it comes to priority population serviced by your agency/group, do you currently serve the Latino population?

Yes

Not Applicable

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* 20. Needs (we will address all needs to the best of our ability):

	Yes	No
Wheelchair accessibility?	Wheelchair accessibility? Yes	Wheelchair accessibility? No
Do you have any special needs?	Do you have any special needs? Yes	Do you have any special needs? No

Please explain

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* 21. How did you hear about this event? (check all that apply)

My supervisor

My professor

A colleague

A classmate

Someone from another organization

A website

Print media (i.e. newspaper)

Social media (i.e. facebook, twitter)

The Latino Commission on AIDS

Center for Latino Adolescent and Family Health

Other (please specify)

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* 1. Salutation

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* 2. First Name

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* 3. Last Name

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* 4. Email AddressNote: Please provide an accurate email address. This is the delivery method of your registration confirmation, and any other information regarding the event.

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* 5. What is your work affiliation? Check all that apply.

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* 6. Place of employment

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* 7. Work Address

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* 8. City

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* 9. State

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* 10. Zip

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* 11. Work Phone Number

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* 12. What is your agency or program Facebook username, if applicable?

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* 13. What is your agency or program Twitter username, if applicable?

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* 14. Gender

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* 15. Race / Ethnicity

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* 16. Sexual Orientation

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* 17. Primary language

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* 18. Highest level of education

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* 19. When it comes to priority population serviced by your agency/group, do you currently serve the Latino population?

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* 20. Needs (we will address all needs to the best of our ability):

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* 21. How did you hear about this event? (check all that apply)

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* 22. What are you expectations for the event?

* 4. Email Address

Note: Please provide an accurate email address. This is the delivery method of your registration confirmation, and any other information regarding the event.