Lakewood Black Caucus Registration Form

Lakewood Black Caucus Registration & Event Form

Fill out the form carefully for registration
Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender*
Race/Ethnicity*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Company or Organization
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Want to RSVP for upcoming event or program?*

Snack & Chat - (please select specific dates below)Kwaanza - Saturday, December 27th, 12:00 pm - 5:00 pmBlack History Month - Saturday, February 21st, 12:00 pm - 5:00 pmBlack Room Meeting - (please select specific dates below)Juneteenth - Friday, June 19th, 12:00 pm - 5:00 pm
Please select from the following dates if you are RSVP'n for a Black Room Meeting or Snack & Chat. Please Note: All Snack & Chats and the Black Room Meetings, will be tentatively held from 1:00 pm - 4:00 pm on a Saturday.

Snack & Chat - April 18, 2026Snack & Chat - August 15, 2026Snack & Chat - October 17, 2026Black Room Meeting - January 27, 2026Black Room Meeting - March 21, 2026Black Room Meeting - May 16, 2026Black Room Meeting - September 19,2026Black Room Meeting - November 21, 2026
Number of guest attending?
Additional Information? (anything we should know about our guest? disabled, special occasions, children, veteran etc. All are welcome and will be accommodated!)
Should be Empty:

Lakewood Black Caucus Registration & Event Form