Interest Form for LEAD Health Advocacy:Cohort for LGBTQ+ & Questioning Youth Survey

The next cohort will start June 2nd.

Thank you for your interest in LEAD Health Advocacy, Mazzoni Center's health and wellness educational group for LGBTQ+ and questioning youth! Participants who complete the program will receive a $100 gift card. Please fill out the survey below and we will be in contact soon.

UPDATE: All spots for the June cohort have been filled. Please fill out the form if you are interested, and you will be contacted for the next cohort (exact date TBD but likely in the fall).

1.Please enter your contact information so we can reach out to you. We primarily communicate via Email.
We will not share this information. (Required.)

Name you go by (first and last)

Pronouns

Email Address

Confirm Email Address

Phone Number (please use the following format: xxx-xxx-xxxx)

2.Do you identify as LGBTQ+ or questioning?
**This group is for folks that identify as LGBTQ+ or are questioning**(Required.)

Yes

3.Are you between the ages of 18-24?
** This group is only for folks in that age range.(Required.)

Yes

4.Are you based in Philadelphia or the surrounding area?
**This group meets in person in Philadelphia**(Required.)

Yes

5.Do you have any barriers to attending all 8 sessions? They will likely be held 5-7pm on Tuesday evenings.

If yes, what day(s) work better for you?(Required.)

6.Where did you hear about this group?(Required.)

7.Do you have access to transportation to get to center city?
** This is a weekly, in-person group meeting at 1348 Bainbridge. (Required.)

Yes

Other (please specify)

8.Do you have any allergies or dietary restrictions?
** We are working to provide snacks/food at all meetings. We will do our best to accommodate everyone's dietary needs.(Required.)

9.Do you have any accommodation needs we should know of?
Ex. Need larger fonts, need a scent free space, etc.

Current Progress,

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