Course Registration Form

Registration Form

Fill out the form carefully for registration
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Do not fill out

Street Address Line 2

CityState

Zip Code
Student E-mail (or parents email)
example@example.com
Parents email (if students email is above)
example@example.com
Black Children's Book Week Pledge.

I promise to...
- Stay informed about my history
- Continue to gain knowledge
- Understand and share legacies of those who paved the way for me
- Be honest and have integrity
Signature

Clear
Please verify that you are human*
Should be Empty: