WyAETC Program Registration

You must complete the entire form in order to register for the web conference.
If you have additional questions about the conference,
please contact the WyAETC office directly: 307.265.0413

Registering for: WyAETC & Denver PTC HIV/STD Update (monthly web conference)

Part A. Participant Information

First Name:

Last Name:

Credentials (needed for CE):

Agency:

Mailing Address:

City:

State:

Zip Code:

Telephone:

Contact Email:

Part B. HRSA AIDS Education and Training Centers Participant Information Form

1. To create your unique ID number, use the month of your birth, day of your birth, and last four digits of our SSN.
For example, May 29, 123-45-6789, has the ID number 05296789.

2. Today's Date (mm/dd/yy)

6a. Primary Employment Setting/Zip Code

Rural
Suburban
Urban

6b. Primary Employment Setting Zip Code

7. Is the employment setting a faith-based organization?

Yes
No
Don't Know

8. Does the employment setting receive Ryan White Program funding?

Yes
No
Don't Know

If you don't know, please write the full name of your employer:

9. Are you of Hispanic, Latino/a, or Spanish origin?

Yes
No

10. Your Racial Background (Select all that apply)

11. Your Gender

Female
Male
Transgender

12. Do you provide services directly to clients/patients?

Yes
No (Stop here. Skip to Part C of this form.)

13. Do you provide services directly to HIV-infected clients-patients?

Yes
No/Don't Know (Stop here. Skip to Part C of this form.)

14. How many years have you been providing services directly to HIV-infected patients/clients?

15. Estimate the NUMBER of HIV-infected clients/patients to whom you provide direct services to in an average MONTH?

For questions 16-18, estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who were:

16. Racial or Ethnic Minorities