HIV Test and PrEP Navigation Services--Referral Program

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Ran by the HOPE (HIV, Outreach, Prevention and Education) Program at AACI, we offer a referral program to be used as an incentive for our other programming including the GLOW (Getting the Low-down On Wellness) Sexual Health Program, HIV Testing and PrEP Navigation services.

Once you attend your HIV or PrEP Navigation Services appointment you will receive a $25 Gift Card from Amazon or Target.

PrEP Navigation Services:
❏ Email: hope.PrEP@aaci.org
❏ Phone: 408-278-4138
HOPE HIV testing and counseling services
❏ Email: hope@aaci.org
❏ Phone: 408-278-4138

First Name:

Last Name:

E-Mail:

Phone #:

I am interested in scheduling an HIV Self-Test Appointment:

Yes

Clear selection

I am interested in PrEP Navigation Services:

Yes

Clear selection

If you come from the GLOW Program, who was your trainer:

What was the date of your GLOW training?

YYYY

I am not in the GLOW Program, but I am interested in being a:

Participant (Receive $10 Gift Card)

Trainer (Receive a $250 Gift Card)

Not Interested

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms