Individual Registration

Please enter information in the form below to process registration for event Our Faith Lights The Way - 1000 Congregations Sign-up.

First name*
Last Name*
Organization*
Address*
City*
Country*
State*
Zip*
Phone*
Email*
Website Address
Mobile Phone
Leader's Name
Leader's Title
Contact Person
Please select the religious affiliation that your congregation represents*
Tell Us About Your Event
Is this your first time hosting an HIV Testing event?
If no, how many years have you hosted an event?
Will you need technical assistance?
For a Coalition of Congregations - Our Coaltion will
Organize a one-time community-wide event with HIV testing as the focus Organize a one-time community-wide event where HIV testing is one of the many screenings offered Host a series of HIV testing events throughout the month of June Other  
Additional screenings to be offered (check all that apply)
STD TB additional tests will not be offered  
Congregational Size
Mobile Telephone*
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