PRO Project Client Registration

First Name *

Middle Name

Last Name *

Preferred Name

Preferred Gender Pronoun *

She He They Other

If other gender pronoun

Address

Apt #

City

State

Zip Code

Age *

Date of Birth

Cell Phone

Email *

Is discretion necessary for Mailings and Calls? *

Yes No

Are you currently employed?

Yes No

Current Employer

Occupation

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Are you currently receiving or have you received services at the Los Angeles LGBT Center in the last six months? *

Yes No

Please list the program(s) from which you have received services

Gender

Female Male Gender Non-Conforming Genderqueer Trans man (F to M) Trans woman (M to F) Choose not to identify

Sexual Orientation

Asexual Bisexual Gay Lesbian Straight Pansexual Queer Questioning Choose not to identify

Ethnicity

Latino/a/x Asian/Pacific Islander Native American African American/Black Caucasian/White Choose not to identify

Educational Attainment

No schooling completed Some high school, no diploma HS diploma Some college, no degree Bachelor's degree Graduate/professional degree

Current Income

Over $50,000 $36,000 - $50,000 $26,000 - $35,000 $15,000 - $25,000 Under $15,000

Reason for visit *

Resume Cover Letter Interview Preparation/Mock Interview Job Search Strategies

How did you hear about the PRO Project?

YES! I am interested in receiving more information regarding Center programs and events. *

Yes No