Youth-Led Research Program Sign-up
*
First Name
*
Last Name
*
Email Address
*
What pronouns do you use?
* Please tell us your pronouns.
She, her, hers
He, him, his
They, them, theirs
Other
*
Street Address
Apartment number or other address details
*
City
*
Zip Code
Youth Phone
*
School (our program is for teens who are currently in high school)
Best way to contact
Email
Text
Phone call
*
Date of Birth (our program is for teens ages 15-19)
Clear
*
Current grade
9th grade
10th grade
11th grade
12th grade
Other
*
T-shirt size
S
M
L
XL
XXL
T-shirts are unisex sizes
*
Do you require any accommodations? (do you receive additional support at school (like an IEP)? Do you need certain kinds of support for your mental or physical health?)
*
Why are you interested in participating in the Local Circles' Action Team?
Parent or Guardian Name (first and last)
Parent or Guardian Phone Number
Parent or Guardian Email
Best way to contact Parent or Guardian
Email
Text
Phone call
Submit
