Youth AFFIRM

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Youth AFFIRM

Please answer the following questions so we can register you for the training and be sure to accommodate any childcare and dietary requests.

Email *

Please enter your first and last name here *

Please enter your address with zip code here *

Please enter your birthdate (MM/DD/YYYY) *

What is the best method to contact you about AFFIRM? Please share as much information as possible to help us coordinate communication with you. For example: Contact me at (xxx)xxx-xxxx by texting after 3p and before 9p. *

Are you involved with any of the following systems? *

Child Welfare

Mental Health

JPO

None

Required

What pronouns do you use? *

She/Her/Hers

He/Him/His

They/Them/Their

Ze/Zim/Zir

No Pronouns

Prefer Not to Answer

Other:

What is your sex assigned at birth? *

Female

Male

Prefer not to answer

What is your gender identity? *

Female

Male

Genderfluid

Agender

Non-binary

Genderqueer

Questioning/I don't know

Prefer not to answer

Other:

What is your sexual orientation? *

Asexual

Bisexual

Gay

Lesbian

Pansexual

Queer

Same Gender Loving

Straight/Heterosexual

Questioning/Don't Know

Prefer not to answer

Other:

What is your race? (Choose one or more) *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Other:

Required

What is your ethnicity? *

Hispanic/Latinx

Non-Hispanic

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How did you get referred to AFFIRM

School

Caregiver/parent

Caseworker

Therapist

Media/Marketing Message

Other:

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Would you like to be added to our info list to be the first to hear about upcoming events, programming and opportunities to connect with us? *

Yes

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