ShoutOUT Registration Form | Centre LGBT+

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814-308-9670

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ShoutOUT Signup Form

Name of Parent/Guardian

Email

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Name of Youth

Pronouns

Youth Date of Birth

Current Grade in School

Any allergies?

Anything else we should know working with your child?

By checking this box you acknowledge that transportation to and from group is the parents/guardians responsibility and Centre LGBT+ is not responsible if your youth leaves group for any reason. Any approved adults you list on this form should bring their ID's with them when picking your child up.

Please list any adult who is approved to pick up your child from group. Full name and phone numbers. If you are the only person please also mark that down.

Thank you for helping us make a difference!

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Thanks for submitting!

© 2025 by Centre LGBT+.

Centre LGBT+

204 E Calder Way

Suite 304

State College, PA 16801

814-308-9670

hello@centrelgbtplus.org

© 2025 by Centre LGBT+.

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