Suicide Prevention Task Force Application

Contact Information & Demographics

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* 1. The Youth Suicide Prevention Task Force regularly discusses sensitive topics, including suicide and self-harm. These conversations may be emotionally triggering. Please care for your well-being, if you need immediate support, call or text 988. Do you understand and wish to continue your application?

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* 2. How do we contact you?

Name *

Address

City/Town

State/Province

ZIP/Postal Code *

Email Address *

Phone Number

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* 3. How do you describe your race or ethnicity? (select all that apply)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino/a/x

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Prefer not to answer

Another race or ethnicity (please specify)

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* 4. Are you a youth under 24 years of age?

Yes

No

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* 5. What are your pronouns? (ex. He/him, She/her, They/them, She/they)