National Coalition for LGBTQ Health Membership Form

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Join the National Coalition for LGBTQ Health to
advance LGBTQ health equity.

First Name*

Last Name*

Position/Title

Organization*

Address, line 1*

Work Phone*

City*

State*

Zip Code*

Email Address*

Which of the following LGBT health issues do you or your organization primarily work to address?

Clinical / Medical Provider

Yes No

Behavioral Health

Yes No

Gender Identity

Yes No

Physical Health/Fitness

Yes No

Sexually Transmitted Infections (STIs)

Yes No

Stigma/Discrimination

Yes No

Violence

Yes No

Health Insurance/Care Access

Yes No

Which of the following populations do you primarily work with or for to address issues related to LGBT health?

Youth (under age 25)

Yes No

Seniors (over age 60)

Yes No

Gay/Bisexual Men

Yes No

Bisexuals

Yes No

Lesbians

Yes No

Transgender Men/Women

Yes No

Heterosexual Allies

Yes No

African-Americans/Blacks

Yes No

Hispanics/Latinos

Yes No

Asian/Pacific Islanders

Yes No

Native Americans/Alaska Natives

Yes No

Immigrants/Refugees

Yes No

Substance Users

Yes No

Sex Workers

Yes No

Incarcerated/Formerly Incarcerated Persons

Yes No

Individuals with Disabilities

Yes No

Has your organization produced resource materials (i.e., guides, white papers, websites, curricula, etc.) that you would like to have listed as part of the Coalition's resource library?

Yes No

Are you a provider?

Do you provide HIV Services?

No, I do not currently/have never provided HIV-related services Yes, I provide/have provided HIV-related services

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