Project TEACH Fields marked with an asterisk (*) must be completed in order to register. "*" indicates required fields Step 1 of 2 50% Name* First Last Todays Date: MM slash DD slash YYYY Date of Birth: MM slash DD slash YYYY Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Can we add you to our email list? Yes No Home Phone(###) ###-####Cell Phone(###) ###-####If you don’t answer, can we leave a message?: Yes No Where can we say we are calling you from?: Project TEACH Philadelphia FIGHT Education ContactsIf we can’t reach you at the numbers you listed above, is there someone else we can contact?: Contact Person #1 First Last PhoneCan we leave a message?: Yes No Where can we say we are calling you from?: Project TEACH Philadelphia FIGHT Education Contact Person #2 First Last PhoneWhere can we say we are calling you from?: Project TEACH Philadelphia FIGHT Education What is your gender? Female Male Transgender MTF Transgender FTM Other What is your sexual orientation? I identify myself as lesbian or gay I identify myself as bisexual I identify myself as straight Other What is your ethnicity? Hispanic Non-Hispanic Other What is your main racial or ethnic group? African American/Black White (Non-Hispanic) Latino or Hispanic Asian or Pacific Islander American Indian /Alaskan Mixed Other What is your current employment status? Unemployed Disabled Part-time Full-time Income generated in non-traditional ways (i.e., street economy) Don’t know Other Do you utilize some form of health insurance? No Yes Other If you answered yes, what type? First Choice Second Choice Third Choice What is your yearly income range? $0.00 $1.00 to $10,830 $10,831 – $14,570 $14,571 – $18,310 $18,311 – $22,050 $22,051 – $25,790 $25,791 – $29,530 $29,531 – $33,270 $33,271 – $37,010 and more Other How many household members does this income support?Where have you been staying during the past seven days? Your own place, a room, apartment, or house that is your home Temporarily doubled up with others, in someone else’s house/apartment/room A temporary or transitional SRO (Single Room Occupancy) facility, or a welfare hotel or motel In a shelter for homeless people In jail, prison, or a halfway house In drug treatment, a detox unit, or drug program housing In a hospital, nursing home, or hospice n an abandoned building, a public place like a bus station, a store or another place not intended for sleeping On the street, or anywhere outside such as a park/under a bridge, in a campground Someplace else Other Has a doctor or health care provider ever told you that you have AIDS? Yes No What was the month and year of that diagnosis?TEACH ProgramsWhy do you want to participate in the program?How did you hear about Project TEACH?How did you hear about Project TEACH?What questions do you have about staying healthy with HIV/AIDS, HIV/AIDS treatment, or medical care issues?What skills would you bring to Project TEACH, based on past training, employment or volunteer experience?Would you be willing and able to commit 6 hours per week for 8 weeks? Yes No Would you need any assistance or special arrangements in order to participate? Yes No If you answered yes, please explain:Have you ever completed any of the following TEACH Programs? Latino TEACH TEACH Outside Womens TEACH Youth TEACH Project TEACH What Year Did You Complete Latino TEACH?What Year Did You Complete TEACH Outside?What Year Did You Complete Women's TEACH?What Year Did You Complete Youth TEACH?What Year Did You Complete Project TEACH?EmailThis field is for validation purposes and should be left unchanged. Δ
