African Heritage Classroom Committee Membership Application

Please check off the membership category you want.

qCategory 1 (Student $10.00): For persons 18 years of age or younger, and all University of Pittsburgh students 23 years of age or younger.

qCategory 2 (Individual $15.00): For persons over 18 years of age, and all University of Pittsburgh students over 23 years of age.

qCategory 3 (Family group $25.00): For a maximum of two adults in a single household, and their children 18 years of age or youner living in the same household.

qCategory 4 (Organization $50.00): For businesses and officially name educational, religious, social, and cultural groups.

Additional Contribution $_____________. The AHCC gladly accepts donations in addition to membership dues to support our programs.

Total Enclosed: $________________

Name:

Name:

(Name of 2^nd adult if Category 3, or contact person if Category 4

Address

Street and apt number

Address

City, State, Zip Code

Home Phone#	Business Phone#
Email 1	Email:
Name	Name
Name of Child if Category 3	Name of Child if Category 3
Name	Name
Name of Child if Category 3	Name of Child if Category 3

Preferred Payment Options:

Check: Please make payable to the University of Pittsburgh-AHCC and return to the address below. Also place AHCC in the memo section of your check. Thank you for your support!

Credit card: Visaq Master Card q Discover q

Card number Expiration date

Your signature: