LGBTQ+ Community Center Information Form

Your Information

We expect that you are an authorized representative of this LGBTQ+ Community Center. If you are not, please reach out to the center and ask an authorized representative of the center to complete this form.

Your Name*

First Last

Your Role

What is your primary role with the center? For example, “Programs Coordinator”, “Youth Outreach”, etc.

Your Email Address*

Enter Email Confirm Email

Your Phone Number*

LGBTQ+ Community Center Information

LGBTQ+ Community Center NAME*

LGBTQ+ Community Center PHONE NUMBER*

LGBTQ+ Community Center WEBSITE

LGBTQ+ Community Center ADDRESS*

This is the physical address of the center; the location where your patrons are directed. If your mailing or shipping address is different, please mention it in the comments.

Street Address Address Line 2 City State ZIP Code

What programs does your center currently offer for young adults?*

What impact do you believe a Gayme Night would have at your center?*

Addional Information

Message / More Information

If there is anything else you would like to add, please do so.