VACAC RSVP

VACAC Dinner
PROVIDE ID #
OFFICE USE ONLY
Todays Date

MonthDayYear
Date
RSVP for:
Have you registered for a MHC event in 2026?
Event Date

MonthDayYear
Date
Hour MinutesAM/PM Option
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?
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?
Age Range
Date of Birth

MonthDayYear
Date
Current Age
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?
Minority Health Consortium (MHC)

CONFIDENTIALITY AGREEMENT

(Revised & Legally Strengthened)

Revised May 25, 2026

As a participant in support groups, meetings, retreats, or events hosted, sponsored, or facilitated by the Minority Health Consortium (“MHC”), I acknowledge that I may be present with individuals who have disclosed or may disclose personal, sensitive, or protected health information, including HIV status.

By signing this Agreement, I understand and agree to the following:

1. Definition of Confidential Information

“Confidential Information” includes, but is not limited to:

Personal, medical, or identifying information shared by any participant
HIV status or any other health‑related information
Information shared verbally, in writing, electronically, or through observation
Any details that could reasonably identify another participant
Confidential Information may be communicated through verbal discussions, written materials, electronic messages, voice communications, or any other form of disclosure.

2. Obligation of Confidentiality
I agree that:

I will not disclose, share, repeat, or confirm any participant’s personal, medical, or identifying information to anyone who did not attend the same MHC event.
I will not disclose the identity of any participant, including their presence at an MHC support group or event.
I will not record, photograph, or otherwise capture images, audio, or video during any MHC support group or event unless explicitly authorized in writing by MHC.
I will respect the privacy, dignity, and confidentiality of all participants, staff, volunteers, and facilitators.

3. Purpose of Confidentiality
I understand that MHC is committed to protecting the privacy and safety of all participants, particularly individuals living with HIV or other sensitive health conditions. Confidentiality is essential to maintaining a safe, supportive, and stigma‑free environment.

4. Prohibited Conduct
I agree that I will NOT:

Discuss another participant’s health information, HIV status, or personal story outside the group
Share screenshots, messages, or content from virtual meetings
Reveal who attended an MHC event
Use information obtained through participation for gossip, harassment, discrimination, or any harmful purpose

5. Consequences of Breach
I understand that any violation of this Agreement may result in:

Immediate removal from the support group or event
Revocation of my privilege to attend future MHC programs
Notification to appropriate authorities if the breach violates state or federal law
Potential civil or criminal liability under applicable confidentiality, privacy, or health information laws

6. Acknowledgment and Agreement
By signing below, I acknowledge that:

I have read and fully understand this Confidentiality Agreement
I agree to comply with all confidentiality policies and procedures established by MHC
I understand the importance of maintaining a safe and confidential environment
I accept full responsibility for safeguarding all information shared during MHC support groups or events.
Do you agree the Confidentiality Agreement?
PARTICIPANT AGREEMENT OF EXPECTATIONS AND WAIVER
Updated May 25, 2026 Minority Health Consortium (MHC) & VACAC Central

As a participant in support groups, meetings, retreats, or events hosted, sponsored, or facilitated by the Minority Health Consortium (“MHC”) or VACAC Central, I understand that participation is a privilege and that certain behaviors are required to maintain a safe, respectful, and supportive environment.

By attending, I agree to the following expectations:

1. Participation and Conduct

I agree to:

Participate fully in all activities to the extent my health permits.
Arrive on time for all scheduled meetings, sessions, and group activities.
Be considerate, respectful, and supportive of others at all times.
Refrain from disruptive, aggressive, or disrespectful behavior.

2. Substance Use

I agree to:

Be free of alcohol or illegal drug use or possession during all MHC/VACAC events.
Understand that if I violate this expectation, I will be required to leave the event immediately and at my own expense, and may be barred from future participation.

3. Smoking and Phone Use

I agree to:

Refrain from smoking inside any building or meeting space.
Not make or receive phone calls during sessions. If an urgent call is necessary, I will step outside the meeting area quietly and respectfully.

4. Confidentiality

I agree to:

Respect the confidential nature of all aspects of MHC/VACAC meetings and events.
Not share, repeat, or disclose any personal information, stories, identities, or experiences of other participants.
Protect the privacy and dignity of all attendees.
(A separate Confidentiality Agreement may also apply and must be followed.)

5. Respect for Beliefs and Boundaries

I agree to:

Respect different belief systems, backgrounds, and lived experiences.
Refrain from any form of proselytizing, evangelizing, or attempting to convert others to my personal beliefs.

6. Personal Property and Program Materials

I agree to:

Not take any items, materials, or property that are not explicitly given to me.
Understand that taking items without permission will result in immediate removal at my own expense and may result in being barred from future events.

7. Assumption of Risk and Liability Waiver

I understand and agree that:

I participate in MHC/VACAC support groups, meetings, and events at my own risk.
MHC and VACAC Central are not liable for any injuries, accidents, or incidents that may occur during participation, including travel to and from events.
I am responsible for my own health, safety, and personal belongings.

8. Acknowledgment and Agreement

By signing below, I acknowledge that:

I have read and fully understand the expectations outlined in this Participant Agreement.
I agree to abide by all rules, expectations, and guidelines to the best of my ability.
I understand that failure to comply may result in removal from the event and/or loss of future participation privileges.
Do you give MHC to obtain your HIV information from your HIV care agency?
Clients Signature
Organization Rep Signature
Should be Empty:

VACAC Dinner