Pride Without Fear San Diego / Tijuana Binational Conference 2026 YOUR CONTACT INFORMATIONName(Required) First Last PronounsTitleOrganization(Required)What is your primary rold in your organization(Required) ADAP Program Coordinator/Manager Administrative Support Staff Board Member Case Management Staff Chair - Planning Council/Planning Body Clinical Quality Staff Community Member Consultant Data Staff Federal Staff Fiscal Staff Grant/Contract Support Member - Planning Council/Planning Body Patient Navigator Peer Navigator/Community Health Worker Principal Investigator Project Coordinator/Director Provider Social Worker Other, please describe below If Other, please describeContact Information Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Mobile Phone (if different than "Phone")Email(Required) SPECIAL NEEDSPlease check all that apply Kosher Meal Spanish Translation Sign Interpretation Vegetarian Meal Vegan Meal DEMOGRAPHIC INFORMATIONAge Range:(Required) Under 20 20-24 25-34 35-44 45-54 55-64 65+ Sexual Orientation:(Required) Asexual Bi+ Gay Heterosexual Lesbian Pansexual Prefer Not to Disclose Queer Questioning Same Gender Loving Two Spirit Racial Identity:(Required) African Alaska Native Black Carribean Hawaii Native Latinx Native / Indigenous/ First Nations Pacific Islander Prefer Not to Disclose White Racial Identity Not Listed:HIV Status Person Living with HIV Person Living without HIV Undeclared Unknown CONSENT FOR PROMOTIONAL MATERIALSConsent By submitting this registration information, you are confirming your release for any attendee/speaker/exhibitor for all and any audio/visual content, created or recorded by VIDA and/or a partner/participant, at any VIDA conference/event.1. Authorizes VIDA as the event organizer to record any and all individuals via audiovisual activities including but not limited to photography, videography, audio records, webinar records, livestreaming, etc. • Further, VIDA can create assets for educational and marketing purposes and share those assets via the organization's print and digital platforms as well as in-person events. • Further, VIDA is the sole owner of the audio/visual assets that the organization records. 2. Absolves VIDA from endorsing any facts, views, and opinions express by the speakers and attendees at in-person or online events convenened by the organization and any of its initiatives. 3. Authorizes, without liabiilty to VIDA, for participating organizations and/or individuals , to record any and all individuals, in audiovisual activities including not limited to photography, videography, audio records, webinar recordings, livestreaming, etc.
