Please enter your registration amount:   

     The total registration cost to include, as appropriate:

• Community registration: $30
• CEU credit for Registered Nurses(5.5 hrs) cost $100
• Additional contribution for scholarships: your choice

In order to get a broader understanding of our diverse community, we request that you please complete the following optional questionnaire:

1. Age   

2. Title   

3. Race/Enthicity   

4. ASLinterpretation/Other Accomodations needed:    

5. Sexual Orientation:
    Lesbian  Bisexual  Gay  Heterosexual  Other 

6. Gender Identity:
    Female  Male  Transgender  Other 

7. Area where you live   Rural  Suburban  Urban

8. Relationship status:
    Single  Married  Domestic Partner  Living Together

9. Are you parenting?   Yes  No    Age(s) of child(ren) 

10. Are you a grandparent?   Yes  No    If yes, how many grandchildren? 

11. Occupation:   Activist  Healthcare provider  Researcher
    Policymaker  Non-profit worker  Artist  Educator
    Other 

12. Your annual income:
     0 - $24,999
     $25,000 - $49,999
     $50,000 - $74,999
     $75,000 - $99,999
     $100,000 - $124,999
     $125,000 or more

13. How did you hear about the National Lesbian Health Summit?
     Flyer  Email  Blog  Word of mouth  Ad
     At an event