Peer Support Sign Up Form
We're so excited to welcome you to the Youth Era family. Whether you're interested in coming to events, joining our groups, looking for support, or learning how to improve your life, there is something for everyone here.

You only have to sign up once to be able to attend all of our future events and receive peer support.

Some of this information is used to receive funding so we can keep providing all our events for free, so please fill it out as best as you're able to.

If you have any questions feel free to reach out to Nick Clark, Program Manager at nclark@youthera.org or 971-978-9797.
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Your Basic Information
First Name* *
Last Name  *
Preferred Name
Birth Date (please include full year) *
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/
DD
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What City in Columbia County are you in? Or if outside Columbia County, which County and City are you in? *
What's the Best Address for Us to Deliver Event Supplies To?
Pronouns *
Required
Gender identity *
Ethnicity *
Required
Experiences - check all that apply *
Required
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