Registration for Support Group

LGBTQ+ Summer Support Group for Teens

Meetings will be Wednesday, June 7th through Wednesday, August 2nd from 3:30 pm to 4:30 pm at Hoyleton located at 8 Executive Dr in Fairview Heights. If you have questions please contact the clinical department at 618-688-4727

Question Title

* 1. Please provide contact information

Name

Address

Address 2

City/Town

State/Province

Email Address

Phone Number

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* 2. What is your age?

13-14

15-16

17-18

Question Title

* 3. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

Question Title

* 4. What school do you attend?

Question Title

* 5. Parent or guardian contact information

Name

Email Address

Phone Number