Hazelden Publishing: Register: Addiction Alliance of Georgia - Family and Children's Services Orientation

Addiction Alliance of Georgia - Family and Children's Services Orientation

Complete these questions to add an attendee to the Event.

First Name *

Last Name *

Date of Birth

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Email *

Email Confirm *

Phone *

How many are attending?

Relationship

Select the statement that best describes you in relation to a person experiencing or seeking care for substance use.

New or renewal *

State You Live In *

Who has referred you to this service?

Referred by location

At which site is the person who referred you for this service from?

What is your gender identity?

Race or Ethnicity

How would you describe your race or ethnicity? (select all that apply)

American Indian or Alaska Native (origins in original peoples of North, Central, or South America)

Asian (origins in East, Southeast, or South Asia)

Black or African American (Origins in Black racial groups of Africa)

Hispanic or Latino (Mexican, Puerto Rican, Cuban, Dominican, Central/South America, or Spanish origin)

Middle Eastern or North African (Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)

Native Hawaiian or Pacific Islander (Hawaiian, Samoan, Chamorro, etc.)

White (origins in Europe)

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