AAP Adolescent HIV Prevention Project
Registration Form

Please provide the following contact information in order to receive more information or network regarding HIV/STD prevention in youth.

Name:
Preferred Address:
City:
State:	Alaska Alabama Alberta Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico Newfoundland New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
E-mail Address:
Phone Number:
Please add me to the AdolHIV e-mail list.	YES, please add me. NO, please do not add me.
I would like more information. The issue or question I have is:

In order to best serve you, please provide us with the following information about yourself.

Please describe your current occupation:

General pediatrician Adolescent specialist Pediatric infectious disease specialist Other physician Public health practitioner Medical school faculty Educator (of youth) Community-based organization staff Administration, public health Administration, education Other administrator Other:

Please describe your primary site of employment.

Private practice Clinic University Medical Center School (primary/secondary) University Public health department Other:

What is your professional background? (Please check highest level of credentials that apply. More than one can be chosen.)

High school/GED College Masters degree PhD MD/DO CHES (health educator) Other certification:

To what extent do you work with the following minority youth populations on a regular basis:

None to Limited Contact Some Contact Considerable Contact Great Contact Latino African-American Asian Native American

Please describe your current level of experience for the following activities:

Situation No experience Some Occasional Experience Regular/ Ongoing Experience Considerable Experience/ Current Occupation I have worked with a school-based clinic. I have collaborated with education personnel and/or schools. I have worked with the state's coordinated school health project. I have collaborated with public health personnel. I have collaborated with pediatricians and other medical staff. I have worked with HIV programs that have been called "promising" or "best" practices. I have worked with adolescents at high-risk for HIV infection. I have worked on health policy development. I have worked on school policy development. I have read about/attended seminars on community collaboration, coalitions, etc. I have been a member of a coalition.

At what level of programmatic and policy work are you most involved?

Community State National

Thank you for your interest in adolescent HIV prevention.