First Name Last Name

Address   City

State   Zip

Phone Number

E-mail Address

Please check the box next to only two workshops you would most like to attend.  We will make every effort to place you in the workshop you desire most, however where there are scheduling conflicts, we reserve the right to place you based upon availability:

Law and Black Society

Mentoring Programs

Educating Black Males

Spiritual Growth

Would you like to purchase a hot lunch or box lunch for $5.00 at the conference?

Yes No

If yes, specify:

hot  box

Would you like to purchase the "Official" Conference T-shirt for $10.00? (view sample)

yes  no

 If yes, please specify size:

youth   large   XL   2XL   3XL