Registration Form

Hidden Fields

Facilitator's Email

Group ID

Program Type

Registration Status

Group Type?

Registration Status

Public Group Description

Group Description

Contact Details

First Name

Last Name

Age

Birthdate

Primary Email

Primary Phone Number

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Thank you for your interest in this group. Unfortunately, due to age limits for our Youth Programming, this group is not available.

Please visit our GROUPS PAGE for another group.

Primary Address

Street Address

Apartment Number

City

State

Zip Code

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Demographics

Pronouns

Pronouns (Self-Describe)

Gender

Gender (Self-Describe)

Transgender

Sex assigned at birth

Sexual Orientation

Prefer to Self Describe:

Race

American Indian, First Nations, or IndigenousAsian (including East, Southeast, and South Asian)Black, African-American, African Descent, or Afro-CaribbeanHispanic or Latino/a/xMiddle EasternNative Hawaiian or Pacific IslanderWhiteMore than one racePrefer to self describeDecline to answer

Race (Self-Describe)

How did you hear about us?

Other

Country of Origin

Have you entered the US in the last 12 months?

Are you currently in a shelter or have you stayed in one in the last 12 months?

Have you ever received case management services from our team?

Commitment and Personal Statement

In 500 words or less, please tell us more about yourself and what you hope to gain from attending this group. Please also include any experience you have had with other support/discussion groups:

I understand this group has a total of 10 meetings and in order to receive the full incentive amount, I cannot have more than 1 absence. Please note two lates equal 1 absence.

Thank you for your interest! Unfortunately, registration is closed due to being at capacity. Please keep an eye out for future groups and events on our website www.gaycenter.org