Name *

First Name

Last Name

Phone Number *

(###)

###

####

School or Organization Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Workshop Location Information (optional)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you requesting a workshop or representatives for a health fair?

Workshop

Health Fair

Date you are requesting us to attend this engagement:

MM

DD

YYYY

The workshop(s) or health fair will take place in a:

Classroom

Auditorium

Other

What ethnicities are represented in your audience?

(Please check all that apply.)

African American

Asian/Pacific Islander

Caucasian

Hispanic

Native American

Other

Will the participants have received any HIV education from your school/program this school year prior to our visit?

Yes

No

Does your school or program serve one or more of the specific groups listed below?

(Please check all that apply.)

LGBTQ

Juvenile Justice/Court Involved

Foster Care

PLWHA

ESL (please specify a language below)