Register
Organization Information:
 
Name:*
Address:*
City:*
County:*
State:*
Zip Code:*
Phone:*
Fax:
www
 
 
Describe your organization:
 
 
Do you offer HIV Testing in a regular basis?
No Yes
Describe the HIV testıng service (type of test) including address (if different from Agency's address), hours of services, days, contact person and other relevant information.
 
Do you have a mobile to provide HIV testing?
Yes No
 
Are you willing to share the mobile van with other agencies for HIV testing?
Yes No
 
 
Contact Person Information:
 
Name:*
Title:*
Phone:*
E-mail:*
   
 
 
List of Services you Provide:
   
HIV Prevention and Health Education Food/Home Delivered Meals
Counseling and Testing Prison Program
Case management Outreach
Primary Care Drugs Abuse
Mental Health Rental Assistance Program
Support Group Insurance Assistance – ADAP
Housing Legal Services and Client Advocacy
Job Counseling and Work Placement Immigration Services
Other (please specify) LGBT Services
 
 
 
Security Code: *
   
 


 
 Project Wave (PW) New York: receive incentives to distribute in your event!! - To continue supporting LHTM events PW has decided that as long as you submit your request 2 weeks in advance of your event, they will try their best to provide you with the incentives. Download the forms and familiarize yourself with the process.
3 step Incentive
Event Request Participation Form
Event Data form
Incentives Received form
Incentives Tracking Form

 DBR Inc Productions is offering video and promotion for your HIV Testing event. For additional information please call Sharryl Travis at (646) 281-22234 or email her at saved4lifefoundation@gmail.com