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PA HIV JUSTICE ALLIANCE
If you would like to part of the PA HIV Justice Alliance , please respond to the following:
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Cell Number (Optional)
Your answer
Age Range
*
18-24
25-34
35-44
45-54
55-64
65+
What County do you live in?
*
Your answer
Gender/Gender Identity
*
cisgender female
cisgender male
transgender female
transgender male
non-binary
two-spirit
sexual orientation
heterosexual
lesbian
gay
bisexual
queer
asexual
intersex
Clear selection
Which race or ethnicity best describes you? (Please choose only one.)
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity/ Other (please specify)
prefer not to answer
Clear selection
Whether you identify as a person with HIV, HIV- or Don’t Know/Prefer not to Say
*
Person Living with HIV
HIV negative
don't know/prefer not to say
Any experience with or association with HIV, advocacy or social justice organizations? (please list).
Your answer
Have you been part of any regional or national PLHIV networks?
Yes
No
Maybe
Clear selection
If yes, please list the networks
Your answer
Please identify areas of skills or talents
Doing research
Writing letters
Organizing meetings
taking notes
Connecting with newly diagnosed
Serving on advisory boards or planning councils
Voter engagment
Speaking to people
Education
Sharing my lived experience
Other
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