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LBP Program Registration
1.
Registration Date (day/month/year)
2.
Program of Interest
Project Takeoff
Project P.U.S.H - Boxing Program (based on funding)
Lifted Thursdays - Music mindfulness program
Tattoo Stories - Photo and storytelling exhibit (based on funding)
GiftEd - Artist development program (based on funding)
3.
First Name, Last Name (preferred name)
4.
Date of Birth (day/month/year)
5.
Gender Pronoun
He/HIm/His
She/Her/Hers
They/Them/Theirs
6.
Address
Address
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
7.
Emergency Contact Person (First Name, Last Name, Relationship)
8.
How do you think this program will be beneficial to you?
9.
What types of trainings, workshops and programs would be of interest to you? Is there any additional information our team should know about you, to better support your needs?
10.
How did you hear about our programs and services?
Social Media
Email
Referral from another organization
Flyer
Friend/Family member
other
Current Progress,
0 of 10 answered