BRSG REGISTRATION FORM

Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Office Phone Office Phone - ### - ### ####
Email
Affiliation
Number of Registrants
Name of Guest/s

Please separate each guest's name with a comma.
Status

Status Faculty Student Clergy Laity

Check all that apply
Payment

Payment Check Paypal/Credit Card
Please make checks payable to the Black Religious Scholars Group, 411 21st Ave. S., Nashville, TN 37240. All checks must be received prior to November 10, 2017.

Please make checks payable to the Black Religious Scholars Group, 411 21st Ave. S., Nashville, TN 37240. All checks must be received prior to November 10, 2017. I have read and agree
Please submit credit card payment through the Paypal link at the bottom of the confirmation page.

Please submit credit card payment through the Paypal link at the bottom of the confirmation page. I have read and agree