Please tell us a bit about yourself:

First Name

Last Name

Pronouns

Work Phone

Work Email

Please tell us a bit more about the organization you represent:

The name of your group/organization

Your Title

Group/Organization's website

Street address of organization's headquarters

City

State

Zip-Code

please enter a 5-digit zip code

*Required field

What best describes your organization? Please check all that apply.

Aging Service Provider Aging and Disability Resource Center Senior Center State Unit on Aging Veterans Affairs Advocacy and/or Policy Organization Local – State Group/Org National Group/Org Area Agency on Aging Religious Center Senior Services Division (gov't) Supportive Housing Services LGBTQ+ Health CenterLGBTQ+ Community GroupLGBTQ+ Community Center/OrganizationOther

Please describe.

Is your organization recognized as a nonprofit by the Internal Revenue Service?

YesNo

Does your current work focus on serving or advocating for LGBTQ+ older people?

YesNo

Do you focus on serving/engaging any of the following as part of your LGBTQ+ elder community? Check all that apply.

Transgender, gender nonconforming, gender non-binaryBlack/African AmericanNative/Indigenous/First NationsLatino, Latinx, or HispanicHIV+RuralNot Listed, Please SpecifyNone at this timePeople Living with Disabilities

Please describe.

If your work does not currently serve or advocate for LGBTQ+ older people, do you plan on serving/engaging any of the following? Check all that apply.

Please describe.

Contact Information