REGISTRATION FORM

Name __________________________________________________________

Address ________________________________________________________

City ______________________ State _____ Zip Code _________ Country ____

Phone Number _____________________ Fax or Email ____________________

Gender ______________ Age _________

Languages Spoken

_______________________________________________________________

Are you homeless, low income, unemployed or other?

_______________________________________________________________

Group or Organization

_______________________________________________________________

Name of Emergency Contact

_______________________________________________________________

Phone Number of Emergency Contact

_______________________________________________________________

What dates will you be in Philadelphia for the March For Economic Human Rights?

_______________________________________________________________

What kinds of financial, material or skill contribution can you make to the March?

_______________________________________________________________

Will you be bringing your children along? __________

Names and Ages of children attending:

_______________________________________________________________

_______________________________________________________________

Do you have any medical problems or dietary concerns which our staff should be aware of?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

 

RULES: In order for the March For Economic Human Rights to be safe and successful, we all must follow some rules. In addition, it is essential that we respect the leadership of the organizers throughout the March and while at the Tent City.

No drugs, alcohol or violence will be tolerated.

Each person may bring only one duffel bag.

 

I, ____________________________________ , agree to follow and respect the leadership of the March organizers.

Signature ____________________________________

Witness ____________________________________

 

MAIL OR FAX TO:

Poor People's Economic Human Rights Campaign

c/o Kensington Welfare Rights Union

PO Box 50678 * Philadelphia, PA 19132

(215)203-1945 * fax (215)203-1950

kwru@libertynet.org * http://www.kwru.org