Minority Health Trans Night & Dinner March.22.2022

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Full Name* This field is required.
First Name
Last Name
2
Will you be attending the Trans Night & Dinner?
YESNO
3
Phone Number* This field is required.Enter a valid phone number
4
E-mail* This field is required.Enter a valid email address
example@example.com
5
What is your City and Zip Code?
Enter your city or county of Residence
Enter your current Zip Code
6
ABOUT YOU Self-identification is essential, and we understand that we each understand words used to describe our own experiences. So that we may best honor your identity and experiences, please describe how you identify in the free-response box AND select (as many as you want) from the list in the next section following this question.* This field is required.How Do You Identify?
In your own words, what is your gender-identity/
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Select the term(s) with which you most identify, even if the same as above* This field is required.Check all that apply
Agender
Cisgender (non-trans) Man
Cisgender (non-trans) Woman
Gender-Non-conforming
Gender Variant
Genderqueer
Intersex
Non=binary
Transgender Man
Transgender Female
Not listed
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Please share your pronounsPlease share your pronouns. Pronouns are the part of speech used to refer to someone in the third person. We want to know how to respectfully refer to you!
She/Her/Hers
He/Him/His
Ze/Hir/Hirs
They/Them/Theirs
No Pronoun
No Preference
Not Listed
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Do you require a vegetarian meal?
YESNO
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Do you have any food allergies?If yes, please list in the next box.
YESNO
11
Please list any food allergies in the text box.
Huge
Large
Normal
Small
Ok
Ok
12
Have you been Vaccinated against COVID-19?Please check all that apply
Yes, I have received my first dose
Yes, I have received my second dose
Yes, I have received the booster dose
No, I have not been vaccinated
I decline to disclose my vaccination status
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If you would to be contacted about future programming by email, please enter your mail below to give us permission to contact you. Enter a valid email address
example@example.com
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Suggestions if any for future programs you would like to see implemented for the Trans Community:Please list any programming you would be interested in seeing implemented at the Community Engagement Center in the future?
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SignaturePlease sign here to acknowledge that you: 1. I will not divulge or breach any participants' confidential information. 2. I will photograph any participant without their knowledge or consent. 3. I understand that is my responsibility to follow COVID-19 precautions, such as hand washing, using sanitizers, mask-wearing, and proper social distancing.
ClearPlease place signature in the box above.
Should be Empty: