/ Continuing Education/ TransActive Support Group Application

TransActive Support Group Application

Please provide the information requested below. Once you’ve submitted the completed form, a member of our staff will contact you to provide further information.

If you are self-registering as a Vanguard member (age 14-17) without a parent or guardian, please register yourself under adult 18+ but note that you will be attending Vanguard.

Please note: Participation in these peer support groups is not therapy, a substitute for therapy, or to be labeled as therapy. Those who are interested in options for counseling and therapy may call the Lewis & Clark Community Counseling Center at 503-768-6320, or complete an inquiry form.

All fields marked with asterisk (*) are required.

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Youth Participant Information (age 17 and under)

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Youth first name (assigned or chosen):

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Youth last name:

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Birthdate:

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They identify as:

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Gender pronoun:

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If other, please enter the pronouns used:

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Youth’s age:

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Group they are attending:

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Adult Participant Information (age 18+)

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First name (assigned or chosen):*

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Last name:*

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You identify as:*

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Gender pronoun:*

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If other, please enter the pronouns used:

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Relationship to youth participant:*

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Group you are attending:*

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Self-Registering Vanguard Birthdate

If you are a Vanguard member self registering, please provide your birth date.

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Phone number:*

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Is it safe for us to leave a message and give our organization name?:*

Yes

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Email:*

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Additional Adult Participant (if any)

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First name (assigned or chosen):

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Last name:

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They identify as:

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Gender pronoun:

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If other, please enter the pronoun used:

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Relationship to youth participant:

select menu field

Group they are attending:

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Phone number:

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Is it safe for us to leave a message and give our organization name?:

Yes

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Email:

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Additional Minor Participants

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If there are no additional minor participants, please scroll to the bottom of the page to submit your enrollment request.

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First name (assigned or chosen):

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Last name:

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Birthdate:

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They identify as:

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Gender pronoun:

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If other, please enter the pronoun used:

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Youth’s age:

select menu field

Group they are attending:

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Enter additional minors/children (if any) below:

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PLEASE NOTE: Upon receipt of this form, a member of the TransActive Gender Project staff will contact you within 72-hours at the email listed to confirm your submission and provide further information.

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