✕
LASA Services Registration
Name/Nombre
(Required)
First
Last
Street Address/dirección de la calle
City/ciudad
Zip Code/código postal
(Required)
Your Phone/número de teléfono
Your Email Address/Tu dirección de correo electrónico
Age/e dad
(Required)
Please enter a number from
1
to
99
.
Gender/Género
(Required)
Select
Female
Male
Trans Male (FTM)
Trans Female (FTM)
Gender Non-Conforming
Refused /Don’t Know
# in Household/# en el hogar
(Required)
Select
1
2
3
4
5
6
7
8
Military/Militar
(Required)
No
Yes
Disability/Discapacidad
(Required)
No
Yes
Race/Carrera
(Required)
Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Multi-Racial
White
Refused /Don’t Know
Ethnicity/etnicidad
(Required)
Select
Non-Hispanic/Non-Latinx
Hispanic/Latinx
Refused / Don’t Know
Sexual Orientation/Orientación Sexual
(Required)
Select
Heterosexual
LQBTQ+
MTF
FTM
Prefer Not to Say
Income Level/Nivel de Ingresos
(Required)
Select
Up To $24,350
Up To $40,550
Up To $64,900
Income Level/Nivel de Ingresos
(Required)
Select
Up To $27,800
Up To $46,350
Up To $74,150
Income Level/Nivel de Ingresos
(Required)
Select
Up To $31,300
Up To $52,150
Up To $83,400
Income Level/Nivel de Ingresos
(Required)
Select
Up To $34,750
Up To $57,900
Up To $92,650
Income Level/Nivel de Ingresos
(Required)
Select
Up To $37,550
Up To $62,550
Up To $100,100
Income Level/Nivel de Ingresos
(Required)
Select
Up To $41,960
Up To $67,200
Up To $107,500
Income Level/Nivel de Ingresos
(Required)
Select
Up To $47,340
Up To $71,800
Up To $114,900
Income Level/Nivel de Ingresos
(Required)
Select
Up To $52,720
Up To $76,450
Up To $122,300
Select all services/ seleccionar todos los servicios
(Required)
Computer Lab/ Laboratorio de computación
Food Pantry/ Despensa de alimentos
Shower/ ducho/ ducha
Washer/Dryer/ Lavadora/Secadora
Diapers/ Pañales
Water Asst./ Asistente de Agua
Heating/Cooling/ Calefacción/Enfriamiento
Essential Needs/ Necesidades Esenciales
Workshop
Naloxone/ Naloxona
Other: Specify/Otro: Especificar
Describe other services you are receiving/ Describe otros servicios que estás recibiendo
(Required)
Comments
This field is for validation purposes and should be left unchanged.
Reset Form
Name/Nombre
(Required)
First
Last
Street Address/dirección de la calle
City/ciudad
Zip Code/código postal
(Required)
Your Phone/número de teléfono
Your Email Address/Tu dirección de correo electrónico
Age/e dad
(Required)
Please enter a number from
1
to
99
.
Gender/Género
(Required)
Select
Female
Male
Trans Male (FTM)
Trans Female (FTM)
Gender Non-Conforming
Refused /Don’t Know
# in Household/# en el hogar
(Required)
Select
1
2
3
4
5
6
7
8
Military/Militar
(Required)
No
Yes
Disability/Discapacidad
(Required)
No
Yes
Race/Carrera
(Required)
Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Multi-Racial
White
Refused /Don’t Know
Ethnicity/etnicidad
(Required)
Select
Non-Hispanic/Non-Latinx
Hispanic/Latinx
Refused / Don’t Know
Sexual Orientation/Orientación Sexual
(Required)
Select
Heterosexual
LQBTQ+
MTF
FTM
Prefer Not to Say
Income Level/Nivel de Ingresos
(Required)
Select
Up To $24,350
Up To $40,550
Up To $64,900
Income Level/Nivel de Ingresos
(Required)
Select
Up To $27,800
Up To $46,350
Up To $74,150
Income Level/Nivel de Ingresos
(Required)
Select
Up To $31,300
Up To $52,150
Up To $83,400
Income Level/Nivel de Ingresos
(Required)
Select
Up To $34,750
Up To $57,900
Up To $92,650
Income Level/Nivel de Ingresos
(Required)
Select
Up To $37,550
Up To $62,550
Up To $100,100
Income Level/Nivel de Ingresos
(Required)
Select
Up To $41,960
Up To $67,200
Up To $107,500
Income Level/Nivel de Ingresos
(Required)
Select
Up To $47,340
Up To $71,800
Up To $114,900
Income Level/Nivel de Ingresos
(Required)
Select
Up To $52,720
Up To $76,450
Up To $122,300
Select all services/ seleccionar todos los servicios
(Required)
Computer Lab/ Laboratorio de computación
Food Pantry/ Despensa de alimentos
Shower/ ducho/ ducha
Washer/Dryer/ Lavadora/Secadora
Diapers/ Pañales
Water Asst./ Asistente de Agua
Heating/Cooling/ Calefacción/Enfriamiento
Essential Needs/ Necesidades Esenciales
Workshop
Naloxone/ Naloxona
Other: Specify/Otro: Especificar
Describe other services you are receiving/ Describe otros servicios que estás recibiendo
(Required)
Comments
This field is for validation purposes and should be left unchanged.
