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Please help us with the A Donde Vayas Salud (Wherever you go Health) project!

If you are interested, please apply by Monday May 11th.

Fill out the application below, or contact Monique Vasquez at 512-495-5266 or monique.vasquez@austin.utexas.edu for more information or to apply.

Please enter your first and last name:

We are looking for people who can commit to attend a series of 5 virtual or phone meetings between May 2020 and September 2021. Are you able to do this?

Yes
Maybe
No

Phone number:

Email:

Ethnicity (Choose all that apply)

African-American/Black
Asian-American/Asian
Latina/o/x or Hispanic
None of the above:

What languages do you speak?

What is your gender:

How old are you?

18 - 24 years old
25 - 34 years old
35 - 44 years old
45 - 54 years old
54 - 65 years old
65+ years old

What is your household income?

Under $20,000
$20,001 – $40,000
$40,001 - $60,000
$60,001 – $80,000
$80,001 – $100,000
$100,001 or over

How many people live in your household?

What zip code do you LIVE in?

What zip code(s) or part of town do you primarily WORK in or SPEND TIME in?

If selected, during which of the following times could you be available for the first CES meeting? (Please select all that apply).

Tuesday May 19th 4:00 - 6:00 pm
Wednesday May 20th 4:00 - 6:00 pm
Wednesday May 20th 5:00 - 7:00 pm
Thursday May 21st 2:00 - 4:00 pm
Thursday May 21st 5:00 - 7:00 pm
Monday May 25th 3:00 - 5:00 pm
Monday May 25th 6:00 - 8:00 pm
Wednesday May 27th 4:00 - 6:00 pm
Wednesday May 27th 5:00 - 7:00 pm
Thursday May 28th 2:00 - 4:00 pm
Other times (if none of the above):

Which of the following communities do you belong to or work with? (Please check all that apply.)

Elder/Senior
Families with children
Geographically isolated persons
LGBTQIA+
Low-income persons
People experiencing homelessness/Formerly homeless
People who have been directly affected by incarceration
Multi-generational Austin families (i.e. those living in Austin for at least 3 generations)
Persons not proficient in English
Persons with disabilities
Immigrants
Not listed:

We are interested in hearing from people who can speak about experiences with their health and their health care (as an example: getting and sharing their health information or medical records). If this is you, please share some of that experience and why you are interested in this project.