LBR Interest Form
Every day, young people navigate relationships - crushes, breakups, sexuality, firsts, and hookups - but they don’t always have the space to talk about them, learn about them, or share their experiences and educate others. Let’s Be Real creates that space. Grounded in our belief that everyone deserves a healthy relationship and everyone can take action in their own way, we amplify the voices of young people ages 12-24.

Let's Be Real provides you with online and in-person opportunities to have real conversations about your experiences, tap into your creativity, and apply your individual gifts and talents towards building a culture without abuse. Please fill out this form so that we can get to know you as well as to connect you to resources, events, and opportunities.
Follow us:
Instagram- @breakthecycle
Twitter- @breakthecycleDV

*Responses are used to best match young people with projects and their information is not shared beyond BTC staff*
Email address *
Full Name: *
Pronouns:
How did you hear about us?
How would you describe yourself? (Some projects are looking for specific populations, ex: an LGBTQ group may be looking for a nonbinary speaker for their conference)
Do you identify as transgender?
Clear selection
I identify my ethnicity as.. (This will help us inform our work and better serve our communities)
Date of Birth: *
MM
/
DD
/
YYYY
LBR is a space for students 12-24. Please tell us your age: *
Location: (City, State) *
Phone number:
Best days/ times to contact you? *
Can we follow up with you? If so, what is the best way to contact you? (check all that apply) *
Required
Instagram handle:
Most used Social Media Platform: (Pick one, we want to learn what platforms young people are using the most at the moment) *
Topics that interest you: *
Other Ideas:
Submit
Never submit passwords through Google Forms.
This form was created inside of Break the Cycle. Report Abuse
Google Forms