Mi Centro Client Registration Form

Enrollment Date

At what location are you registering? / En cual centro comunitario se está registrando? *

Center South Mi Centro

I would like resources and information on

If other resources and information, please specify

First Name / Nombre *

Last Name / Apellido *

Gender / Género *

Woman / Mujer Man / Hombre Transgender Woman / Mujer Transgénero Transgender Man / Hombre Transgénero Non-Binary / No Binario GNC / Género No Conforme 2-Spirit / Dos Espirítu Intersex (AFAB) / Intersexual (Mujer asignada al nacer) Intersex (AMAB) / Intersexual (Hombre asignada al nacer) Declined to ID / Declina Other / Otra

If other gender, please specify / Si identificas de otro género, por favor explicanos

Pronouns / Pronombres

Birth Date / Fecha De Nacimiento *

Race / Raza *

If other race, please specify

Email / Correo Electrónico *

Mobile Phone / Número de Teléfono

Zip Code / Código Postal *

Preferred language for call back

English / Inglés Spanish / Español

Is discretion needed for communications?

Discrete Phone Calls / Llamadas telefónicas discretas Discrete Emails / Correos electrónicos discretos Discrete Mailings / Envíos discretos SMS Fax

I agree to the Photo Permission / Autorizo el uso de mi imagen *

Yes No

I hereby agree that I have read and understand the following: Center South Behavioral Agreements; Sexual Harassment Policy; and the Release and Waiver Liability.

Behavioral Agreement *

Yes, I agree.

Click Here to Review LA LGBT Center's Terms of Service

LA LGBT Center's Terms of Service *

I have reviewed and agree accept the LA LGBT Center's Terms of Service (Link Above)

Mi Centro Client Registration Form

Community Programs Registration