LD Alliance Club Interest Form

LD Alliance Club Interest Form

About Your School

What would you like to do?

School Name

Mailing Address

Mailing Address Suite/ Apt # if applicable

City

State

Zip Code

About You

Legal First Name

Legal Last Name

Preferred Name or Nickname

Preferred Pronouns

Gender

Birthday

Email Address

Phone Number

Your Role

Grade Level

Expected Graduation Year

Are you of Hispanic or Latino origin? Check one or more.

Yes, CubanYes, Mexican, Mexican American/ChicanoYes, Puerto RicanYes, other Hispanic or LatinoNo

What race/ethnicity do you consider yourself? Check one or more.

American Indian or Alaska NativeAsian IndianCambodianChineseFilipinoJapaneseKoreanLaotianThaiVietnameseBlack or African AmericanAfricanCaribbeanGuamanianNative HawaiianSamoanCaucasian: EuropeanCaucasian: Middle EasternCaucasian: North AfricanOther

Please describe "other"

About Your Club

Have you been involved with Eye to Eye or the LD Alliance before? Select all that apply

Why do you want to start LD Alliance Club?

How did you hear about LD Alliance?

Contact Information