Trans: A Group Participation Form

Thank you for your interest in being a member of the Los Angeles LGBT Center's TAG Youth Program for ages 12-24! We are excited for you to join us, please take a few minutes to fill out this form so we can get to know you better.

Note: This online form serves as a temporary intake form. Should in-person services and programs be held at the Los Angeles LGBT Center, new members may be asked to fill out physical copies of corresponding paperwork.

* The information provided in this form will be kept confidential and used for internal purposes only.
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Legal Name (First, Last) *
Chosen Name *
Date of Birth *
Email address: *
Phone Number *
We will not contact you by phone, unless we receive previous consent
Where are you located? (City, Zip Code) *
We will not mail you any information, unless you request
In case of an emergency who should we contact for you? Please include name, relationship and number *
What is your ethnicity? *
Are you Hispanic/Latinx? *
What are your gender pronouns? (ex. they, she, he, any) *
Gender identify? *
Sexual Orientation? *
Is it ok to send you emails about our upcoming programs? *
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