YES! I want to be a part of the

The Rural AIDS Action Network

Name:

Organization:

Address:

City/State/Zip:

County

Phone(home/work)

E-mail:

Fax

I describe myself, my affiliations, and my interests as (check any that apply):
PLWA	Person Living with HIV/AIDS
MOM	Mother of PLWA
FAM	Family affected by HIV/AIDS
GLBT	Person supportive of gay, lesbian,bisexual and transgender community
MIN	Person with culturally specific skills or experience
SUPP	One to one emotional support (i.e., concerned individual or friend)
VOL	Volunteer for practical hands-on support (e.g. cleaning, cooking, driving)
SPK	Speaker (person willing to tell their story publicly)
ASO	AIDS Service Organization
TEST	Test Site
GROUP	Facilitated Support Group
HC	Home Care
HOS	Hospice
SW	Social Worker
CM	Case Manager
PHN	Public Health Nurse
RN	Registered Nurse
MH	Mental Health Professional
CD	Chemical Dependency Program
DDS	Dentist
MD	Physician
LEG	Legal Consultant
CLERG	Clergy
EDUC	Educator
COR	Corrections Contact
MEDIA	Press/Media Contact
OTHER

I would like to participate in:
	Information & Referral
	Interfaith Careteams
	Prevention Outreach
	Special Events
	Network Building
	Education