Centre LGBT+ Bigs & Littles Program Youth Referral Form

This program matches LGBT+ youth in middle or high school with LGBT+ adult mentors. Matches will meet at Centre LGBT+ in downtown State College biweekly. Matches will be supported by an on-site BBBS team member.

Who is making the referral?
- Self
- Parent/Guardian
- School Staff
- Other
Phone:*
Email Address:
Name of Participant:*
First Last
Participant's Age:*
Participant's Gender:*
Participant's Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What is the primary reason(s) for referring yourself/this youth to the Centre LGBT+ Bigs & Littles program?*