Youth Group Programming - Registration Form
Hidden Fields
Facilitator's Email
Group ID
Program Type
Please select...
1
2
3
4
5
6
7
8
9
Registration Status
Please select...
Active
Planned
Group Type?
Please select...
Closed
Special Event
Drop-in
Registration Status
Please select...
Open
Closed
Public Group Description
Group Start Date
Group Registration Has Passed
Thank you for your interest in this group! Unfortunately, this group has already begun, and registration is no longer available.
Please visit our
YOUTH PAGE
to explore our other offerings.
Group Description
Contact Details
First Name
Last Name
Age
Please select...
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31+
Birthdate
Primary Email
Primary Phone Number
Check here if it is okay to leave a message at this number.
Check here to opt-in to text messages from The Center regarding appointments or Center programming.
I agree to The Center’s
SMS Terms of Service
and have read The Center’s
Privacy Policy
. Message and data rates may apply. You can unsubscribe at any time by replying STOP to opt out.
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
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Never send mail to this address
Demographics
Pronouns
Please select...
He/him
She/her
They/them
No pronouns (just use my name)
Other
Pronouns (Self-Describe)
Gender
Please select...
Man (cis or trans)
Woman (cis or trans)
Non-binary
Genderqueer/Gender nonconforming
Prefer to self describe
Decline to answer
Gender (Self-Describe)
Transgender
Please select...
Yes
No
Decline to answer
Sex assigned at birth
Please select...
Intersex
Female
Male
Decline to answer
Sexual Orientation
Please select...
Gay/Lesbian
Bisexual
Queer
Questioning
Heterosexual
Asexual
Pansexual
Prefer to Self Describe
Declined to answer
Prefer to Self Describe:
Race
American Indian, First Nations, or Indigenous
Asian (including East, Southeast, and South Asian)
Black, African-American, African Descent, or Afro-Caribbean
Hispanic or Latino/a/x
Middle Eastern
Native Hawaiian or Pacific Islander
White
More than one race
Prefer to self describe
Decline to answer
Race (Self-Describe)
How did you hear about us?
Please select...
Counselor
Social media
Family member
Friend
Health Care Provider
HRA
Internet
School staff
Subway Ad
12 Step Program
Other
Other
Commitments and Group Questions
How long have you been participating in Center Youth programming and services?
Please select...
This is my first time
Around 1 month
Between 1 and 6 months
Over 6 months but less than a year
Over a year
Unsure
Have you completed the intake process with Center Youth?
I have completed the Initial Intake Screening Form (but not an intake interview with a staff member).
I have completed the Initial paperwork and have met with a staff member.
No / I need to start the process.
I am not sure.
This group has a total of 6 meetings that are
2 hours each
. In order to receive the full benefits of group participation, I may only have
1 absence
from the group.
I understand, and I don't think I will have any scheduling conflicts.
I cannot commit to each session, but I would still like to join the group.
I would like to speak with a Youth staff member.
Do you have any dietary restrictions?
Is there anything else you'd like us to know?
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 t
his 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