Dallas County "Tell Your Story" Interest Form

Please share your first and last name.

Please select your age range.

Please share your race/ethnicity.

Please share your primary language(s).

If you answered "Other" to the previous question, please specify the language(s) you speak.

Please share your phone number.

Please share your email address.

How have you been impacted by HIV?

Please briefly summarize your experience with HIV.

Please briefly summarize the measures you take to prevent and/or treat HIV.

Are you willing to share your story on camera for distribution on social media? If so, are you comfortable showing your face? Please explain.