Prevention Outreach Request Form

Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Event Date *

MM

DD

YYYY

Event Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Services Requested: *

Outreach Information Table

Rapid Testing

Presentation

On-site HIV and HepC testing require specific accommodations:

1) Confidential, private space away from event attendees, 2) One table and two chairs, 3) If confidential private space is not available, dividers can be used, and we will need access to electrical outlets for white noise machines.

I understand

Is there a cost to participate in your event? *

Yes

No

Event Population:

White

Black

Latino

IV Drug Users

People Living With HIV or Aids

Baby-Boomers (50+)

Youth (12-18)

Transgender or Gender Non-Conforming

Other