Youth Agency Magazine Project Interest Form
Your Information
LEGAL First Name
Middle Initial
LEGAL Last Name
Preferred First Name
Your Birthday
(MM/DD/YYYY)
Your Email
Your Phone
Street Address
City
State
Zip Code
Gender Identity
Male
Female
Genderqueer/Non-Binary
Prefer Not to Answer
Pronouns
He/Him/His
He/They
She/Her/Hers
She/They
They/Them/Theirs
Custom
Custom Pronouns
Race/Ethnicity
(Please select all that apply)
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latinx Non-Black
Native Hawaiian/Pacific Islander
White
Prefer Not to Answer
How did you hear about this program?
Please select...
Current Participant
Parent
Teacher
School Staff
Coach
Flyer
Social Media
Other
If Other, please tell us here:
Parent/Guardian Information
First Name
Last Name
Parent/Guardian Email
Parent/Guardian Phone
Th
ank you for your interest in the Youth Agency Magazine Project.
If you have questions, please contact
armando.banchs@bigthought.org
.
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