The ROCK Summit Registration | 20 February 2026

The ROCK Summit Registration Form | 20 February 2026

Please complete this form to register for The ROCK Summit. The information collected helps us understand who is in the room and shape a meaningful convening. For questions, contact Jamie Nicole at info@aipbipoc.org.
Name*

First NameLast Name
Preferred Name
If different from your legal name
Email*
example@example.com
Phone Number*
Please enter a valid phone number. Used for importantevent-related communication if needed.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Age Range*

18–2425–3435–4445–5455–6465+Prefer not to say
Race/Ethnicity - Check all that apply*

Indigenous/American Indian/ Alaska NativeAsianSouth AsianBlack/African/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianBiracialMulti-racialLatinX/HispanicPrefer not to sayOther
Gender Identity*

WomanManNon-binary or gender nonconformingPrefer not to sayPrefer to self-describeOther
Self-describe gender identity if applicable
Do you identify as transgender?*

YesNoPrefer not to say
Which best describes your role or sector? Check all that apply.*

Public HealthHealthcare ProviderResearcherPolicy or GovernmentCommunity Health WorkerNonprofit or AdvocacyStudent or TraineeIndustry or Private SectorPatientCaregiverOther (please specify)
If you are representing a group or organization, please let us know below the name of the specific organization/group. If none, put N/A.*
i.e. Lupus Foundation, Elusive Ladies and Gents, MG Holistic Society
Who do you primarily serve in your work? Check all that apply.*

Patients or clients with chronic illnessPatients or clients with autoimmune diseaseCommunity members or residentsStudents or traineesPolicy or systems-level stakeholdersResearchers or academicsOrganizations or institutionsGeneral publicI do not work directly with a specific populationOther (please specify)
Who do you primarily serve in your work? Select the top two.*

Research insights or emerging evidenceCommunity and lived experience perspectivesPolicy or systems-level dialoguePractical tools, strategies, or frameworksCollaboration or partnership opportunitiesKnowledge exchange and shared learningI am exploring and open to learningOther (please specify)
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The ROCK Summit Registration Form | 20 February 2026