Membership Form Date * MM DD YYYY Name * First Name Last Name Email * Phone (###) ### #### Gender Male Female Non-Binary Transgender Highest Grade Completed Some schooling, no high school Some High School High School (Diploma or GED) Some College Associates Degree College Degree or Higher Other Credential (Degree or certificate) No Formal Education Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address Type * Home Homeless If address is homeless only put city and state Are you Spanish/Hispanic/Latino? * Yes No What is your primary Ethnicity? * For example American, African, Chinese, Middle Eastern, Haitian, Puerto Rican, Cuban, European etc) What do you consider your race? * ex: White, Black, Asian, Hispanic, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Bi-racial, multiracial (list as many as apply to you) In what language do you prefer to read or discuss health related materials? How did you hear about us? Would you like to have a staff or member call you for follow up? Thank you!
