JOIN US FOR OUR 2ND ANNUAL NATIONAL HIV TESTING DAY EVENT JUNE 26-27
COTE PLAGE 24 CARREFOUR # 6 CONTACT INFO 561-577-2698 OR +509 48512713
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Email address
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EVENT REGISTRATION
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YYYY
LAST NAME
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FIRST NAME
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GENDER
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MALE
FEMALE
AGE GROUP
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0-20 YEARS OLD
20-40 YEARS OLD
40-55 YEARS OLD
55+ YEARS OLD
EVENT ACTIVITIES (PLEASE SELECT YOUR ACTIVITY)
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FREE HIV TESTING
FREE CONDOMS MALE OR FEMALE
FREE LUBRICANT
FREE BLOOD PRESSURE CHECK
FREE FEMININE HYGIENE
FREE SYPHILIS TESTING
FREE SAMPLE OF PrEP
RAFFLE TICKET TO WIN A PROM DRESS
1 TICKET 150 GOURDES
2 TICKETS 300 GOURDES
3 TICKETS 450 GOURDES
4 TICKETS 600 GOURDES
5 TICKETS 750 GOURDES
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HOW DID YOU HEAR ABOUT THIS EVENT?
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PLEASE SELECT YOUR LOCATION
CARREFOUR
AUX CAYES
DELMAS
MARTISSANT
COTE PLAGE 18-26
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