Skip to primary navigation
Skip to main content
Health + Wellness
Clinic
HIV/STD Testing
HIV Services
Mental Health
Support Groups
Life757
Life Health Programs
Intimate Partner Violence
Mail Order Condoms
All Health Services
Understanding Pronouns
Transportation
Housing
Events
Calendar
Dining Out For Life
Dinner Is Served
Reel it Out
Help
Contact Us
Resources
FAQs
Volunteer
Trainings & Workshops
Life Blog
About
Mission + History
Staff + BOD
Locations
Media Center
Contact Us
Jobs
Donate
Search this website
LGBT Life Center
Call Us
(757) 640-0929
Email Us
info@lgbtlifecenter.org
Home
/
Life757
/
LIFE Community Advisory Board Application
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Website
Submit