Trans Wellness Center Registration Form

I would like resources and information on ... *

If other resources and information, please specify

Enrollment Date

Last Name *

First Name *

Upload Your Photo

Street Address *

City *

State *

Zip Code *

Email *

Birth Date *

Is discretion needed for communications?

Discrete Phone Calls / Llamadas telefónicas discretas
Discrete Emails / Correos electrónicos discretos
Discrete Mailings / Envíos discretos
SMS
Fax
TL - Phone
TL - Text Message/SMS

Mobile Phone

Gender *

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 (Asignada Mujer al nacer)

Intersex (AMAB) / Intersexual (Asignado Hombre al nacer)

Declined to ID / Prefiero no declarar

Other / Otro género

If Gender is other, please specify

Gender at Birth *

Pronouns *

If Pronoun is other, please specify

Ethnicity *

If Ethnicity is other, please specify

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

I agree to the Photo Permission

Yes / Sí

No

I agree to grant to the L.A. LGBT Center and its authorized representatives permission to record on photography, film and/or video, pictures of my participation. I further agree that any or all the material photographed may be used, in any form, as part of any future print and/or online publications or materials used to promote the L.A. LGBT Center, and further that such use shall be without payment of fees, royalties, special credit or other compensation.

I agree to the Behavioral Agreement *

Yes / Sí

By agreeing to this contract, I will abide by the Behavioral Agreement rules for the safety and well-being of myself and others.

Trans Wellness Center Membership Form

Trans Wellness Center Registration