2014 National HIV/AIDS and Aging Awareness Day Event Registration

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Please take a few moments to complete the following NHAAAD Event pre-registration form. The registration will take less than 5 minutes of your time. We thank you in advance for registering your NHAAAD event. A complete list of events will be featured on The AIDS Institute's NHAAAD Website: www.NHAAAD.org. After September 18th, we will contact you to submit a post event evaluation survey to gain valuable feedback. Upon completion of the post event evaluation survey, a certificate of NHAAAD participation will be provided.

For additional planning materials and guidance, please visit www.NHAAAD.org.

Organization Information

Name of Organization (or Group) *

Name of Event Organizer(s) *

Title/Position/Volunteer

Email Address *

Address

City *

State *

Zip Code *

Phone Number *

Please include area code.

Organization's Website *

Partnering Organizations, if applicable.

Event Information

Proposed Date of NHAAAD Event

Event Address

City

State

Zip Code

Title of Event

(An event theme is a great way to increase participation)

Type of Event

(HIV testing event, community health fair, media outreach, billboard campaign, awareness or marketing campaign, etc.)

Target Audience

What is the primary audience for your event? (Please check ALL that apply)

People living with HIV/AIDS (PLWHA’s) who are aging with the disease or already over 50 at the time of their initial diagnosis.

Increasing percentage of the population that needs to protect itself from HIV infection, including the growing baby boomer population.

Increasing number of grandparents becoming the primary guardians for children who have lost their parent(s) to HIV/AIDS.

Other:

Secondary Audience

If there is a secondary audience, please indicate it below. (Examples include: churches, senior centers, assisted living facilities, grandparents and grandchildren.)

Anticipated # of attendees

0-50

51-99

100-199

200-499

500+

Clear selection

Additional Attendee Information

(Please check ALL that apply)

The event is open to the public.

The event has a limited number of participants due to funding requirements.

Other:

Will onsite HIV testing be provided?

Yes

Please include any additional information about your event.

If you would like to upload a flyer or provide a link to your event, contact Michelle Scavnicky at MScavnicky@TheAIDSInstitute.org.

Thank you for taking the time to fill out this form.

Event listings will be featured on The AIDS Institute's NHAAAD website: www.NHAAAD.org as registrations are received. This is also a great resource for collaboration and ideas.

Also, we are interested in posting photos from your event, so don't forget your camera!

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