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First Name

MI

Last Name

Title

Clinic/Part C Program

Street Address

Address Line 2:

Zip

Email

Phone

Fax

Which type(s) of Ryan White funding does your clinic receive? (select all that apply)

Part A / Title I

Part B / Title II

Part C / Title III

Part D / Title IV

AETC

Dental

What is the estimated number of patients with HIV in care at your clinic?

How would you describe the community where you practice? (choose one)?

Rural

Suburban

Urban

What issues would you like for the Coalition to address? (max. 1000 characters)

Your race/ethnicity

Asian

Black/African American

Latino/Hispanic

White/Caucasian

Other (Please specify)

Your Gender

Female

Male

Your date of birth

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