Saturday, September 10, 2016

REGISTRATION FORM

Please register and return your completed form by 9/5/2016

(print and mail with payment to address below )

Name__________________________________________________________________

Mailing Address________________________________________________________

City, State, Zip ________________________________________________________

Email address

(Please print clearly) ________________________________________________________

Phone number, including area code____________________________________

Fax number, including area code_______________________________________

Website _______________________________________________________________

Dietary Needs:

___ Vegetarian

___ Vegan

___ Other, Please explain _______________________________________________

Registration Fee: (Check One)

Individual ___$20.00

Seniors/Students & individuals w/limited funds ___ $ 5.00

Local non-profit organizations ___ $25.00

Local large non-profit & National ___ $50.00

Amount included:

Form of payment: (Please circle) Check Cash Other

Please make checks payable to Black United Fund/CAP and mail to:

Black United Fund: 4104 44thStreet Sacramento, CA 95820. Attn: CAP.

Register online at: https://www.eventbrite.com/e/black-lives-matter-tickets-26045198891

(916) 484-5025

The Black Group Voice