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LIFE Community Advisory Board Application

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Gender Identity *

Race *

Ethnicity *

Preferred method of communication *

Email
Text
Phone call
DM (please tell us which app in the comment box below)
Other (please tell us in the comment box below)

DM app or Other (if you checked DM or Other above):

In which settings have you worked? *

Business
Non-Profit/Community Based Organization
City/County/State Government
Education
Faith-based
Medical/Health Care Provider
Military
Self-Employed
Other

Do you currently work? *

Yes, full-time
Yes, part-time
No

Do you currently volunteer? *

Yes, regularly
Yes, occasionally
No

Comment or Message

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Mailing Address: LGBT Life Center, 222 W. 21st Street, F308, Norfolk, VA 23517
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Our offices will be closed on 12/22-25, 12/31 & January 1. Happy holidays!