VACAC Consent to Engage

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Welcome To the Team!All Ryan White Consumers are eligible to join VACAC.
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Are you living with an HIV?* This field is required.
YESNO
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Name* This field is required.Please provide us with your name
First Name
Last Name
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What is your preferred name?Please enter the name by which you would like us to address you
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Phone Number * This field is required.Please enter your phone number if you would like to receive text messages or reminder calls for VACAC Activites
Please enter a valid phone number.
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Subscribers Email By entering your email below, you consent to receive information about VACAC Programming and updates.
example@example.com
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Are you a current member of VACAC* This field is required.Virginia Consumer Advisory Committee
YESNO
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About YouHow do you identify?
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Select the term(s) with which you most identify, even if the same as above?* This field is required.
A gender
Cisgender (non-trans) Man
Cisgender (non-trans) Woman
Gender Non-conforming
Gender Variant
Genderqueer
Intersex
Non-Binary
Transgender
Transgender Female
Not listed
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Please share your pronounsPronouns are the part of speech used to refer to someone in the third person. We want to know how to respectfully refer to you.
She/Her/Hers
He/Him/His
Ze/Hir/Hirs
They/Them/Theirs
No Pronoun
No Preference
Not Listed
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Have your ever participated in a VACAC Live Call before?* This field is required.Have you ever participated in a VACAC Live call before today ?
YESNO
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How likely are you to attend a VACAC program in the future?* This field is required.On a scale on 1 to 5 ?
1
2
3
4
5
Unlikely
Extremely Likely
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Have you been impacted financially by the COVID 19 pandemic?
YESNO
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Please use this space to ask questions you may have questions regarding VACAC. In addition, please share any concerns, ideas for future calls, or topics that you would like VACAC to address.We value your opinions and ideas. We would love to have you engage with VACAC in the future.
Huge
Large
Normal
Small
Ok
Ok
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Are you interested in learning how to become involved in your Regional VACAC in your area?* This field is required.
YESNO
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What Region are you from?* This field is required.
Central
North West
Northern
South West
Eastern
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What city, county, or town do you live in?* This field is required.This will help us determine your region.
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How did you hear about VACAC?* This field is required.Please let us know if your case manager, provider, VACAC member, or someone else told you about us?
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Where do you go for your care and treatment?* This field is required.If you are not currently in care, enter Not in Care in the space below. If you receive care from a Private Care Provider, please enter their Name, Practice, and Phone Number in the space below.
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By signing this HIPPA Compliant request form I am granting permission to VACAC to verify my HIV Status with my provider as proof of my eligibility to participate in a VACAC Regional Team and to receive information regarding VACAC Regional Involvement, Statewide VACAC LIVE Calls, VACAC is Listening Calls, VACAC Summits, Programs, Notifications, and Reminders.* This field is required.Sign this form and submit to consent
Clear
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Thank you for your interest in VACAC Please submit this form it you want to learn more about VACAC, get involved in your regional VACAC, attend VACAC LIVE Calls or Regional VACAC is Listening Sessions or Notify VACAC of a concern you may have.
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