LBP Program Registration

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* 1. Registration Date (day/month/year)

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* 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)

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* 3. First Name, Last Name (preferred name)

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* 4. Date of Birth (day/month/year)

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* 5. Gender Pronoun

He/HIm/His

She/Her/Hers

They/Them/Theirs

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* 6. Address

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 7. Emergency Contact Person (First Name, Last Name, Relationship)

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* 8. How do you think this program will be beneficial to you?

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* 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?

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* 10. How did you hear about our programs and services?

Social Media

Email

Referral from another organization

Flyer

Friend/Family member

other