"It's Your World" 2015 MSM Summit

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Hayti Heritage Center
Historic St. Joseph’s Performance Hall
804 Old Fayetteville Street
Durham, NC 27701
9:00am-5:00pm

This form is for registration and statistical purposes only. It is not our intent to offend anyone in any way, shape or form. This form is strictly confidential to the hosting agency of Triangle Empowerment Center, Inc. only.

Select one

First Name, Last Name *

Preferred Name *

This is the name that will be on your name badge

What pronoun would you prefer for us to use when referring to you? (Optional)

Age

Gender

Sexual Identification (optional)

Heterosexual

Bisexual

Queer

Lesbian

Same gender loving

Other:

Clear selection

Race/Ethnicity

Choose all that apply

American Indian and Alaskan Native

Asian

Black or African American

Hispanic or Latina

Native Hawaiian and Other Pacific Islander

White

Multiracial

Other

Address *

City *

State *

Zip Code *

Best Contact Number *

Email Address

Is this a sponsorship registration? *

If yes, this MUST be filled out by the sponsoring agency/organization

Agency/Organization/Company

Title

Are you a volunteer? *

How did you hear about the summit? *

HIV status (optional)

Positive

Negative

Not sure

Prefer not to say

Clear selection

Meal Preference

Everyone gets 1 boxed lunch meal. Please choose one from below:

Ham

Turkey

Vegetarian

Clear selection

Submit

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