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Donation
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Mandatory fields
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First name
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Last name
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Organization
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Position
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Race/Ethnicity
American Indian or Alaskan Native
Asian
Biracial or Multiracial
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Pacific Islander
White
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NCIMHA has a commitment to diversity, equity, inclusion, and access in our work. Data collected from this question will inform program development and will help NCIMHA identify gaps or disparities . (Please check all that apply.)
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Gender Identity
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
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Email
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Phone
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Amount ($USD)
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Payment frequency
One-time
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