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Models of Pride
Youth Track
Register
LGBTQ Resources
Parent & Professionals Institute
Register
Continuing Education
LGBTQ Resources
Power in Prevention
Info
Accessibility
MOP 30 Youth Registration
Rachel Birkenthal
2022-06-21T14:53:01-07:00
Models of Pride 30 - Youth Registration 2022
Youth Registration
Legal First Name
*
Legal Middle Name
Legal Last Name
*
Preferred Name (If you have one)
Email Address
*
Cell Phone
Birth Date
*
Current City of Residence
*
Current Zip Code
*
Personal Gender Pronouns (she/her/he/him/they/zir/any)
*
(she/her/he/him/they/zir)
Race
*
Black/African American
Latinx / Hispanic
Asian Pacific Islander
Caucasian (Non-Hispanic)
Native American
Multi Racial
Other
If other race, please specify in box below:
Gender Identity
*
Cisgender Woman
Cisgender Man
Transgender Man
Transgender Woman
Gender Queer
Nonbinary
Other
If other gender identity, please specify in box below:
Yes
No
Sexual Orientation
*
Pansexual
Queer
Bisexual
Lesbian
Gay
Straight
Other
If other sexual orientation, please specify in box below:
Choose up to three categories of workshops you would like to see at Models of Pride
Activism / Social Justice / Self-Empowerment
Arts & Culture / Education
Coming Out / Families / Spirituality / Faith
Education / Careers
Gender / Sexuality / Health
People of Color Community & Issues / Ally Community & Issues
Other (enter in box below)
If you would like a workshop category that is not listed, please specify in box below
How did you hear about Models of Pride? (select all that apply)
Previously Participated
Family
Friends
My local LGBT Center
Centerlink or Youthlink
My school
Facebook
Instagram
Other
If other, from whom/where?
We will do our best to provide assistance.
Do you need any of the following accommodations?
ASL interpreting (provide specifics in area below)
Alternative language translation (provide language in area below)
Accommodations details:
Emergency Contact Name
Emergency Contact Phone Number
COVID-19 Proof of Vaccination
*
I will bring proof of my COVID-19 vaccination or a negative test.
By clicking "Yes" I agree to the Models of Pride Release of Liability.
Models of Pride Release of Liability
*
Yes
Release and Waiver of Liability
.
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