VACAC RSVP

VACAC Dinner
PROVIDE ID #
OFFICE USE ONLY
Todays Date*

MonthDayYear
Date
RSVP for:*
Have you registered for a MHC event in 2025?*
Event Date*

MonthDayYear
Date
I am attending as a:*
Please use drop down box to select if you are a client or working for an agency
If other please specify*
I receive my HIV care at:*
Would you like MHC to help you find a new HIV medical provider?

YesNo
Organization I am representing*
If other please specify*
The Minority Health Consortium (MHC) receives Ryan White federal funding through the Virginia Department of Health (VDH). In order to remain compliant with VDH and Ryan White program requirements, it is necessary to collect all information requested on this form. Please ensure that the information provided is accurate. Your personal information is protected by HIPAA and will only be shared with VDH and the Health Resources and Services Administration (HRSA) for funding and compliance purposes.
Name*

Legal First NameMiddle InitialLegal Last NameSuffix
Name you would like to be called (if Different)
Sex Assigned at Birth*
Social Security Number*
Address*

Street Address and Apt #

Apt #

CityState / Province

Postal / Zip Code
Zip Code*
Email*

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number

Race*
Ethnicity: Are you Hispanic/Latino?*
Date of Birth*

MonthDayYear
Date
Current Age*
Age Range*
Do you need transportation to and from this event?*
If yes, please provide address to be picked up from:*

Street Address and Apt #

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have food allergies?*
If yes please list*
Do you require a vegetarian meal?*
Would you like to receive invitations to MHC events via email text or phone call?*
CONFIDENTIALITY AGREEMENT

As a participant of support groups and events, associated with Minority Health Consortium, hereinafter referred to as MHC: I acknowledge and understand that I will be in the company of other HIV positive individuals.

Therefore, I agree to the following "Disclosure of Information" Confidentiality agreement: Disclosure of Information is defined as but is not limited to, verbal discussion, fax transmissions, electronic transmission, voice communication, written documentation. After attending an MHC support group or event, I will not disclose another participant's personal or medical information regarding their diagnosis to any other person who did not attend.

I understand that it is the policy of MHC to protect the confidentiality of all information particularly related to retreat members.

I understand that I will be held responsible for the consequences of any misuse of information gained from my participation with MHC support group or event. I will respect the confidentiality of all retreat members, private or sensitive information accessed in any MHC support group meeting, event or private conversation.

Iwill not disclose the Identity of other MHC support group or event members.

I agree to follow the confidentiality policies and procedures established by MHC. Failure to follow the confidentiality policies and procedures will result in the revocation of my privileges to attend any future MHC support groups or events and/or disciplinary action(s) including criminal charges. By signature below indicates that I have read, understand, and agree to abide by the terms and conditions of this Confidentiality Agreement.
Do you agree the Confidentiality Agreement?*
Participant Agreement of Expectations and Waiver Updated.April 29,2025

If I am invited to participate in The Minority Health Consortium "MHC" or VACAC Central . . support group or event, I understand that there are certa..in behaviors and activities which are appropriate. Therefore, during these support groups / events,

I Agree to the following expectations.:
1. Participate fully in all activities as much as my health permits.
2. Be on time for all scheduled meetings and group activities.
3. Be considerate and helpful to others.
4. Be free of drug and alcohol use or possession. I understand if I break this agreement;. I will be required to leave immediately and at my own expense.
5. Not smoke in any of the buildings.
6. Neither make nor receive telephone calls, except-if you must- Step outside of the meeting area.
7. Respect the confidential nature of all aspects of the MHC/VACAC .meetings and events.
8. Respect different belief systems and refrain from evangelical activities (proselytizing)
9. Do not take items that are not given to me. I understand if I break this agreement; I will be required to leave immediately and at my own expense and could be barrd from attending future MHC/VACAC . support groups or events.
10. I . Attend at my own risk. I agree to not hold Minority Health Consortium or VACAC Central liable for injury or incidents that occur during support groups,meetings or events.
I have read and understand the expectations of an MHC/VACAC Central support group / event participant. I agree to abide by the rules and fulfill these expectations to the best of my ability.
Do you give MHC to obtain your HIV information from your HIV care agency?*
Clients Signature*

Clear
Organization Rep Signature*

Clear
Should be Empty:

VACAC Dinner