HIV 101 Registration

1
Name* This field is required.
First Name
Last Name
2
Phone Number
Please enter a valid phone number.
3
Email
example@example.com
4
Month Selection
Please Select
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
5
Day of Class SelectionPLEASE NOTE THAT IF THE MONDAY FALLS ON A HOLIDAY THE CLASS WILL NOT TAKE PLACE.
2nd Monday
4th Monday
6
Select Payment Option* This field is required.PLEASE NOTE CASH IS NOT ACCEPTED
Credit/Debit Card
Money Order
7
My Products
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
$15 with HIV Test (Most Popular)This option offers an HIV Test as part of the payment.
$15.00Edit
Back
$30 with no HIV TestThis option is offered to those who do not wish to get tested for HIV.
$30.00Edit
Back
Total cost $0.00
Credit Card
First Name
Last Name
8
HIV 101 Class

Acknowledgments

In order to provide the highest quality of services to all of our clients we have drafted the following "HIV 101 Class Agreement" upon signing you acknowledge the following.

BEAT AIDS is a judgment-free zone.

All participants understand that they will need to be at our 230 E Fredericksburg Rd no later than 9 AM.

Classes occur on the first and third Monday of every month.

Classes that may fall on a Holiday Monday will be moved to the following business day. Please call us if you have any questions.

Everyone is encouraged to participate.

Late arrivals MAY be asked to re-register for another class.

In order to receive a certificate participant MUST remain active throughout the entire 2-hour session.

Participants MUST pay prior to taking the class.
9
By signing below you acknowledge the HIV 101 Class agreements.* This field is required.By signing the followng
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