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We invite you to become a member of the National Juneteenth Register.  As a member, you will be included in the dialogue, discussions and information exchange supporting the Juneteenth community.
(We respect your privacy.  Your information will be compiled for composite and statistical purposes only, to help us gauge the social and financial. impact of Juneteenth celebrations across the U.S.)
Individual Registration

Type of Membership:  Individual
First Name:  
Last Name:  
Gender:  Male   Female
Age Group: 0-30     31 - 45     46-55     over 55

Number of children in household:  

Race / Nationality:
State:   Zip:  
Tel:  ()   -              Ext.:
Fax: () -
Web Site:
How did you hear about
How long have celebrated Juneteenth?:  /Years
  Approximately, how many people attend your local Juneteenth event?:  
  Describe your involvement, either as an attendee or event coordinator of the local Juneteenth activities.
  List a few the typical activities hosted at your local Juneteenth event?
  On average, how much would you say you spend while attending your local Juneteenth event?  $  
  On what items do you typically spend money on while attending or in preparation for your Juneteenth event?
  Educational Background - Check box that best applies:

Some High School

High School Graduate

Some College

College Graduate

Post College
*Are you a member of or affiliated with any other national Juneteenth organizations?   If yes, please list affiliations, if no please state "none":
Would you like to receive information from other national Juneteenth organizations?   (Yes / No)               
Tell us about yourself (profession, interests, ambitions, hobbies, etc.)
Your Favorite Web Sites:
Suggestions for the Web Site:
Thank you