The Southwest Michigan Black Heritage Society

NAME:

ADDRESS:

CITY/STATE/ZIP:

HOME PHONE:

CELL PHONE:

E-MAIL

EMERGENCY CONTACT:

EMERGENCY PHONE:

HIGH SCHOOL:

GRADE LEVEL:

What interests you most about the "Telling the Kalamazoo Community Race Story" project? Enter your answer here

What do you hope to gain from the program? Enter your answer here

What skills do you feel you offer?
Enter your answer here

Describe briefly what qualities you have that would make you an asset to this program.
Enter your answer here

Are you able to commit to two Saturdays in the month of October for training?
Yes
No

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