Name *

First Name

Last Name

Phone

(###)

###

####

Country *

USA

Other

Ethnicity *

White or Caucasian

Hispanic, Latino or Spanish

Black or African American

Asian or Asian Indian

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

Other

Birth Date

MM

DD

YYYY

What are your goals or objectives in joining LIF? *

Networking

Job opportunities

Professional Resources

Student grant

Other

Are you interested in volunteering? *

If yes, please answer following question.

Yes

Not at the moment