Youth Reading Group Membership Application

Please complete all questions and answer them accurately. Failure to provide accurate information will delay processing of your application. 

If you are under 18 years of age, you must obtain parental consent before completing this application. Answers are required for all questions marked
'*',  are required and must be filled out.

You may also print this application and send it to us via regular postal mail.r legal guardian before submitting this application.

Email Address *
(If you don't have an email address, click to get a Free email account now.)

Gender

Birthdate (MMDDYYYY)  *

Middle name *

Last name *

First name *

Street Address (Please do not enter a P.O. Box address) *

City State or Province

 Zip or Postal Code *

If you do not live in the state of Georgia or Metro-Atlanta area, 
are you planning to relocate to these areas within the next 3 months ?
*

Country

Phone (Please do not enter a cell phone or pager number) *

Why are you interested in joining Urbane Renaissance Society? (Tip: Please be specific. What you say really matters.)*
 

Please enter a 6 digit or letter password that will be used as your membership id *

Please enter a 6 digit or letter hint to help your remember you membership id *

Select the geographical chapter are you are applying for: *

Select the chapter representing the age group  that is most appropriate for you *

Membership dues are $60.00 per year. Are you willing to accept this financial obligation *?

Questions marked '*' must be answered if you are under 18 years of age.

Please give name of a parent or legal guardian if you are under age 18*  

Legal Guardian's Email Address *

Legal Guardian's Street Address is different from above*

Legal Guardian City *

Legal Guardian State *

  Legal Guardian Zip* 

Legal Guardian Phone*

 

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  What types of literature do you enjoy reading ? To make multiple selections, press the CNTRL key after each selection
 

  What social or civic issues do you enjoy  lending support to ? To select multiple social or civic issues, press the CNTRL key after your selection.

  If there is a civic or social ssue that you would prefer to lend assistance that is not listed in the above selections, please describe it here:

  Please list and describe any civic or social organizations that you have participated in. Please share any awards or honors you received as well:

  What days are most convenient for you to attend or host book club activities ?  

 What times are most convenient for you to attend or host book club activities ?

  Would you like to be added to our marketing mailing list to receive news about upcoming events and opportunities for readers of African American literature?
 

What is your highest level of education attained ?
 

What is your occupation ? (If applicable)

  Are you currently a member of a book club?  If so, give name and location of the book club below:

  Have you ever been a member of a book club ?  If so, please give the name and location of the book club here:

  If you enjoy any genre of literature not listed in the previous choices, please specify here:

  Are there any authors of particular interest to you ?

What kinds of entertainment do you enjoy ?  To select multiple entertainment choices, press the CNTRL key after each selection.  

How did you find out about us? 

___________________________________________________________________

Complete this signature section only of you are printing a hard copy of this application to send by regular mail.

Signature_________________________________

Signature of Parent of Legal Guardian if Applicant under age 18_____________________

Date ______________

____________________________________________________________________________

Thank you for your application !

If your are submitting your application by postal mail please mail to:

The Urbane Renaissance Society

1420 Chardin Drive

Marietta, Ga. 30062

By submitting your registration information, you indicate that you agree to the Terms of Use and have read and understand the Urbane Renaissance Society Privacy Policy . Your submission of this form will constitute your consent to the collection, processing and use of this information by the Urbane Renaissance Society.