Name
*
First Name
Last Name
General Area
*
- - -
LOS ANGELES (Downtown, Echo Park, Hollywood, Koreatown)
SOUTH BAY (Long Beach, Carson, Gardena, Torrance)
SAN FERNANDO VALLEY (N Hollywood, Northridge, Van Nuys, Granada Hills)
SAN GABRIEL VALLEY (Alhambra, El Monte, Baldwin Park, West Covina)
N LOS ANGELES (Glendale, Pasadena, Burbank, Eagle Rock)
WESTSIDE (Santa Monica, Culver City, Venice, Westwood)
OTHER
If "Other", please specify below
Email Address
*
Phone
*
(###)
###
####
Age
*
- - -
< 13 years
13 - 17 years
18 - 29 years
> 30 years
Gender
*
- - -
Male
Female
Parent or Guardian's Name
Parent or Guardian's Phone Number
(###)
###
####
Is this your first time here?
*
- - -
Yes
No
How long have you attended Lord of Harvest LA?
*
- - -
First time
< 1 month
1 - 6 months
6 months - 1 year
> 1 year
Are you in...
*
- - -
Elementary
Middle School
High School
College
Career
Other
How did you find out about us?
*
- - -
I go to this church
Friend(s) or Family
Website (lordofharvest.org)
Social Media (Facebook, Twitter, Instagram)
Other
