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

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,

0 of 9 answered