BLACK HISTORY 4 YOUNG PEOPLE
--- Registration for 12 ~ 18yrs ---
 
Student Name_____________________________________________________Age____
Parent/Guardian Name_____________________________________________________
Address________________________________________________Apt No.#_________
City_______________________________________________State_________________
Home phone_____________________________________________________________
Cell phone______________________________________________________________
Email__________________________________Student Email______________________
Emergency contact________________________________Phone___________________
Is the student taking any medication?  Yes (  )   No  (  )
Will parent/guardian pickup student?   Yes (  )   No  (  )
Fee: $60
Make check or money order payable to: Kwaku Person-Lynn
Send to: P.O. Box 2946, Inglewood, CA 90305
Last day to mail payment: June 11. Otherwise, bring to  first class. Your signature indicates consent to videotape/photograph your child for class promotional  purposes.
IMPORTANT DATES
 
First class begins Saturday June 16 at 10:00am sharp. Class ends at Noon
Location:  AUDUBON MIDDLE SCHOOL – 4120 11th Avenue, Los Angeles, CA
No Class Saturday July 7 th
Information on this form will not be shared with any entity or person.
Parent/guardian must pickup student by 12:15pm
The class is taught in association with African American Studies, Loyola Marymount University
 
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