Louisiana Center for Health Equity Youth Programs Interest Application for 2025
Disclaimer: This application is not an intake form. All programs require individual intake forms that parent/guardian will fill out prior to or at the time of the program's orientation. Parent/Guardian will only have to fill out THIS form one time for all the programs.
Are you a parent, youth/teen, or other?
Please Select
Parent
Youth/Teen
Other
Child Name
First Name
Middle Initial
Last Name
Child Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
No response
T-Shirt Size (Adult Size Only)
Please Select
XS
S
M
L
XL
2X
3X
4X
Parent/Guardian Name
First Name
Middle Initial
Last Name
Parent/Guardian Phone Number
-
Area Code
Phone Number
Parent/Guardian E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would Parent/Guardian be interested in volunteering?
Yes
No
Other
Would you like to receive updates on future events and programs?
Yes
No
Other
It is expected that the parent/guardian drop-off and pick-up their child/children. However, if transportation is needed accomadations may be possible. Will transportation be needed?
Please Select
Yes
No
How did you find out about us
Please Select
Social Media
Word of Mouth
Saw a Flyer
Goodwood Library
Other
Signature
Submit Form
Should be Empty: