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1. Please select the simulators you are interested in participating in and indicate the role you'd like to play:

Note: Simulator Volunteers assist with setup, facilitation, and acting as government entities and social service agencies. Volunteers help create a realistic and engaging experience for participants. Volunteers are expected to arrive 30-mins before the activity begins. (Required.)

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2. Please enter your contact information below: (Required.)

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3. Please enter your date of birth: (Required.)

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PA AHEC's funder Health Resources and Services Administration (HRSA) asks us to collect gender, race, and ethnicity data. PA AHEC recognizes that gender, race, and ethnicity are not meant to fit cleanly into categories, and will continue to advocate for all diversity, equity, and inclusion efforts we are involved in.

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4. Please select from the list the profession that best fits you: (Required.)

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5. Does your employer serve any of the following area(s): (Please select all that apply)

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6. How do you identify your gender? Select one

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7. Race I Identify as:

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8. How do you identify your ethnicity? Select one

The federal government uses these questions to help determine individuals from disadvantaged backgrounds. PA AHEC recognizes that these items in no way determine a person’s ability to serve their community or continue to learn.

Please answer the following questions by checking all that apply.

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9. Please answer the following questions by checking all that apply.

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10. Do you have any accessibility requirements you would like us to be aware of? Please be as specific as possible. (e.g. dietary needs, physical accommodations, learning accommodations, etc.)

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