Online Application Form

For Free Critical Path Email Account

Critical Path Project exists to reach individuals and organizations in underserved communities and enable them to access the resources of the Internet. By completing this form you will get a free email account with Critical Path.

This form is CONFIDENTIAL, in conformance with Pennsylvania HIV Confidentiality ACT 148.

1. First Step

Please pick a login NAME to use with our system.
@critpath.org (this will also be your email address)

Rules: The username must be between 2 and 8 characters long.
But the characters can only be lower case letters or numbers.
You cannot use any punctuation (.!,"?) or special characters (#$%&*) in your username

2. Second Step

Next you need to make up a secret PASSWORD so no one else can use your email or dial-up connection.

Password:
Password (enter again just to make sure):

Rules: Your password must have exactly 8 characters*

*A character is anything you can type with your keyboard

BUT your password MUST contain
At least 2 letter characters (a, b, c, ..., z)
At least 2 number characters (0, 1, 2, ..., 9)
At least 2 punctuation marks (.,!?;:'" and more) or special characters (@#$%^&* and more)

3. Third Step

Please tell us how to reach you.

Name
Organization (optional)
Address
City
State	Zip
Phone

4. Fourth Step

Let us know which area code you will connect from.

215 Area Dial Up Access
610 Area Dial Up Access
609 Area Dial Up Access
856 Area Dial Up Access
302 Area Dial Up Access

5. Fifth step (Optional)

Describe yourself.

Are you:
You live in one of the following types of areas:

Are you one or more of the following:
Person with HIV/AIDS
Health Care Professional
AIDS Service provider
AIDS activist
AIDS researcher
None

Race:

What is your current age?

6. Last Step!

Please click on the submit button one time only. This form will be automatically mailed to the Critical Path Project staff for review. Applications are approved only during business hours (9am - 5pm Monday through Friday) and may take up to 24 hours to be created after we receive and approve them.

Family Centers
critical path project