Name (first & last): *

Pronouns

Date of birth *

Email *

Phone *

What is your gender identity? *

How do you identify ethnically? *

ZIP Code *

Do you live with anyone under the age of 18 in your household?

Please Select

This question is purely for grant reporting purposes and is not shared outside of our organization. Esta pregunta tiene únicamente fines de informe de subvenciones y no se comparte fuera de nuestra organización.

Which programs are you interested in?

LMC (LEA Move Club) - All Ages / Todas Edades

Mi SELA Monthly Program - All Ages / Todas Edades

QT Connect (Queer and Trans Connection) - 18+

Community Clean-Up / Limpieza Comunitaria - All Ages / Todas Edades

YOU Council (Youth Organizers United Youth Council) - Youth / Jóvenes 13-18

PAC (Padres Aliados Conectados) - Parents

Boyle Heights Youth Club - Youth / Jóvenes 13-18

Bell Gardens Youth Group - Youth / Jóvenes 13-18

Boyle Heights GLOW Youth Club - Youth / Jóvenes 13-18

Bell Gardens LGBTQ+ Youth Group - Youth / Jóvenes 13-18

Which of our locations is closer to you? *

Please Select

Allergies or dietary restrictions?

Are you in search of any resources?

Please Select

How did you hear about LEA?

Please Select

If you are a professional that is interested in supporting/collaborating with LEA, please check one more boxes below.

Please Select

Is this your first time registering with LEA? *

Yes! / ¡Si!

No, but I need to update my information / No, pero necesito actualizar mi información

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.