Name *

First Name

Last Name

Phone

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For data and evaluation purposes, please indicate your racial and ethnic identity (select all that apply). *

Biracial or Multiracial

Black, African American, African or Afro-Caribbean

Native American or Alaska Native

Latine/x, Hispanic, or Chicanx

East Asian, Southeast Asian, or Asian American

Middle Eastern, North African (sub-Saharan) or Arab American

Native Hawaiian or Pacific Islander

White or Euro-American

Prefer Not to Self-Identify

Please select the Membership Package that applies to you:

Student Membership ($8 a month)

Student Membership ($80 a year)

Individual Practitioner Membership ($120 a year)

Individual Practitioner Membership ($12 a month)

I would like to request a scholarship