National Lesbian Health Summit Registration Form

National Lesbian Health Summit 2009:
Expanding Our Movement

March 6-8, 2009
University of California, San Francisco (UCSF)

REGISTRATION FORM

Name:

Title:

Organization:

Address:

City, State, Zip:

Telephone:

Fax:

Email:

Payment Information

* Registration costs:

Community registration cost $30

Additional contribution for scholarships:

CEU creditfor Registered Nurses (5.5 hrs) cost $100

* Payment methods:

My check in the total amount of is enclosed
Payable to 'LHRC' (specify 'NLHS' on check memo line)

I am paying with credit card

* Scholarship request:

Briefly describe your economic need for registration cost

*Request for ASL Interpretation or other accomodations :

Please describe any needs for accomodation or interpretation.

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

1. Age
2. Race/Ethnicity
3. Sexual Orientation:
   Lesbian Bisexual Gay Heterosexual Other
4. Gender Identity:
   Female Male Transgender Other
5. Area where you live  Rural Suburban Urban
6. Relationship status:
   Single Married Domestic Partner Living Together
7. Are you parenting?  Yes No  Age(s) of child(ren)
8. Are you a grandparent?  Yes
     If yes, how many grandchildren?
9. Occupation:  Activist Healthcare provider Researcher
   Policymaker Non-profit worker Artist Educator
   Other
10. 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
11. How did you hear about the National Lesbian Health Summit?
    Flyer Email Blog Word of mouth Ad
    At an event

***This registration form should be submitted via fax, email or mail to:

            Lesbian Health & Research Center @ UCSF
            3333 California St., Suite 340
            San Francisco, CA 94118
            Phone: 415.502-5209
            Fax: 415.502.5208
            Email: info@lesbianhealthinfo.org