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Thank you for joining the National Coalition in our work advancing LGBTQ health.

First Name*

Last Name*

Position/Title

Organization

Address, line 1*

City*

State*

Zip Code*

Email Address*

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

Clinical Health Physical Health/Fitness Behavioral Health Gender Identity Sexually Transmitted Diseases/Infections Stigma and Discrimination Violence Health Access Discrimination in accessing health insurance and health care

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

Youth (under age 24) Seniors (over age 60) Gay Men Lesbians Transgender Men Transgender Women Bisexuals Heterosexual Allies African-Americans/Blacks Hispanics/Latin@s Asians/Pacific Islanders Native Americans/Native Alaskans Immigrants/Refugees Substance Users Sex Workers Incarcerated/Formerly Incarcerated Individuals Individuals with Disabilities

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

I'd like to receive updates from this organization

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

Thank You!

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