The LOFT's Rainbow Clubhouse Intake Form

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Thank you for your interest in attending The LOFT's Rainbow Clubhouse! We are always open to new families joining. In an effort to maintain the privacy of our children and protect our families, The LOFT has developed an intake process for new families joining this group. Please complete the form below to the best of your ability. All information given will be kept confidential. Contact information will only be used to contact you about The Rainbow Clubhouse. A LOFT Staff member will be in contact with you via phone following the receipt of your confirmation.

First & Last Name(s): *

Parents/Guardians who would be attending the group. If more than one parent/guardian will be attending please put both names down.

Pronouns used of person completing this form: *

She/Her/Hers

He/Him/His

They/Them/Theirs

Other:

Email: *

Phone Number: *

(###) ###-#### format please.

Check here if The LOFT needs to use discretion when calling or e-mailing you about this group: *

Yes, I would like The LOFT to use discretion when contacting us.

No, anyway of contacting us is fine.

I'm not sure what "using discretion" is.

Required

Is your family involved with any other groups or organizations related to having a gender expressive child? *

Tell The LOFT about your family: *

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