AAFA HEAL Innovation - Michigan Program Application (for people over 18 years old)

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Email *

Mobile Phone #

First Name *

Last Name *

Street Address 1: *

Street Address 2:

City: *

Zip Code: *

What is the best way to contact you? *

Phone

Text/Voicemail

Other:

Best time of the day to reach you? *

Morning (9 am - noon)

Afternoon (noon - 5 pm)

Evening (5 pm - 7 pm)

What is your birthdate? *

YYYY

To which gender do you most identify? *

Man

Woman

Non-binary

Gender non-conforming

Other:

How would you describe your race/ethnicity? Choose all that apply. *

Indigenous American, American Indian, or Alaska Native

Asian

Black or African American

Hispanic or Latino/Latina

Middle Eastern or North African

Arab or Arab American

Native Hawaiian or Pacific Islander

White

Other:

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