Event Registration Register for AIDS Education Month Events If you need any accessibility accommodation or have any questions, please contact us at email@example.com or call 215-985-4448 ext 200. If you would like to volunteer, please visit the volunteer page. 2017 Event Registration Download AEM Paper Registration 2017 Fields marked with an asterisk (*) must be completed in order to register. Is this registration for you?*If you are registering someone else for this event using your personal email address or phone number, please select "No" so we can correctly file this registration.YesNoName* First Last Organization/SchoolAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmailNOTE: You need to enter your email address if you wish to receive an email confirmation of your registration. You will also receive an email that will allow you to easily sign up for further event reminders and updates about AEM. Enter Email Confirm Email Primary Phone*(###) ###-####Mobile Phone(###) ###-####OK to leave a message?*YesNoWhat’s the best way to contact you? Primary Phone Mobile Phone Email Alert Notice: Due to inclement weather, we will be postponing the AIDS Education Month Community Cookout to Saturday, August 26th. We apologize for any inconvenience!Please select all events below that you would like to attend.*Visit the calendar to see more details about events. Opening Reception and Award Ceremony End AIDS: HIV Prevention and Outreach Summit Faith Leaders and Community Summit Community CookoutPOSTPONED to Saturday, August 26th, 12:00 PM – 3:00 PM Beyond the Walls: Prison Healthcare and Reentry SummitWednesday, June 28th, 8:00 AM – 5:00 PM Do you have any of the following professional licenses?Medical Doctor (MD)Registered Nurse (RN)Certified Registered Nurse Practitioner (CRNP)Licensed Social Worker (LSW)Certified Health Education Specialist (CHES)Continuing Education CreditsWhich areas do you intend to receive Continuing Education Credits: Nursing (RN/CRNP) Social Work (LSW/LCSW) Certified Health Education Specialist (CHES) AACO Is this your first time attending an AIDS Education Month event?*YesNoZip code ZIP Code How did you hear about this event?* Attended last year Newspaper Website SEPTA/Bus Ad Partner Organization Mailing Professional association or LSW/LCSW/Nursing/CHES credits In My Neighborhood Other Please select a neighborhoodPoint BreezeHunting ParkOtherZip Code*Please tell us where you heard about this event.*Which partner organization?*Si desea traducción al español durante los talleres, por favor marque aquí. Si Please add me to the eNews list. Yes NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.