HOP
Interest Form

Thanks for your interest House of Poz

House of Poz is held at JASMYN 3 Monday's a month from 5:00pm-8:00pm. This is a brave, supportive space for LGBTQIA+ Young Adults ages 18-29 who are living with HIV.

If you are new to JASMYN, please fill out the brief interest form below and a team member will contact you to talk more about the program.

Name

First Name

Last Name

What are your pronouns?

How old are you?

Have you ever been to JASMYN Before?

Yes

No

What is the best phone number to contact you at?

What is the best email to contact you at?

Do you have a copy of your most recent lab work, POP or Ryan White Card?

We ask for proof of HIV status because this is an identity based group and confidentiality and safe space is important to us.

Yes

No

Not Sure

HOPInterest Form

Thanks for your interest House of Poz

HOP
Interest Form