Address_________________________________________________________ City ______________________________ State _____ Zip Code _________
Phone (including Area Code) ____________ Email_____________________
Name ______________________ Circle-one (spouse, son, daughter, mother, father) Age ______
Name ______________________ Circle-one (spouse, son, daughter, mother, father) Age ______
Name ______________________ Circle-one (spouse, son, daughter, mother, father) Age ______
II. Weekend Registration Section
Events # of Persons x Price = Cost Subtotal for each Event • Concert and Dance _________ x $16.00 = ________ _________
• Meet and Greet _________ x $ 5.00 = ________ _________
• Friday Tours - Slave Haven Museum Tour and Council and Jack Nash, AR . 18 year old to Adult ______ x $17.00 = _________ _________ . 4-17 years _______ x $15.00 = _________ _________
• Saturday Tour -Civil Rights Museum and Al Green Church
. 18 year old to Adult _______ x $24.00 = _________ ________ . 4-17 years _______ x $20.00 = _________ ________
• Banquet: . 12 year old to Adult _______ x $32.00 = _________ _________ . 5-11 years _______ x $17.00 = _________ _________
• Picnic . 12 year old to Adult _______ x $10.00 = ________ _________ . 5-11 years _______ x $ 7.00 = ________ _________
• Tee Shirts . Small___ Medium___ Large___ X Large___ $10 2XL___ 3XL___ $12 ____
Subtotal _______
Annual dues are $25.00 per family (A family is considered head of household and dependents claimed on tax form). $25.00 for dues will be taken off of the top of any amount you send in and you may still have a balance due whatever Reunion activities you want to participate in. If you have already paid your 2009 dues-THANKS!!!
Annual Dues $ _______
Total Enclosed $ _______ Signature: _______________________________________________
Please mail Registration Form and your payment by March 7, 2009 to: Juanita Harmon 1645 N. Rutherford, Chicago, IL 60707
ARKANSAS ARIZONA CALIFORNIA Laura Huddleston -1 Robert Harmon -4 Carrie Garrett -1 Marthelle Qualls -4 Virneeda Owens -3 Rita Qualls -1 Yvette Owens -3 Aisha Williams -1
