National African American Families First & Preservation Association (NAFPA) Membership Application Form
Applicant Personal Details:
Name: |
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Address: |
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Postcode: |
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Home Telephone Number: |
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Mobile Number: |
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Email Address: |
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Date of Birth: |
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Gender (check applicable field):
Male |
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Female |
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Other (please specify) |
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Prefer Not to Say |
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Emergency Contact Details:
Please insert the information below to indicate the person(s) who should be contacted in the event of an incident/accident.
Contact name: |
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Emergency Contact Number: |
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Signature of Member: Electronic or Written |
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Date: |
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Membership Level:
Please indicate the membership type you’d like to hold. Annual dues rates listed below.
Level 1 = $60 | Regular (18-60) |
Level 2 = $45 | Student |
Level 3 = $40 | Senior (60-up) |
Level 4 = $750 | Organization |
If you require any further information or clarification regarding this application, please contact:
Latagia Copeland-Tyronce, MSW
Founder, President & Executive Director
419-297-1250
latagiacopelandtyronce@gmail.com
Completed applications can be emailed at above email address.
DUES CAN BE PAID VIA PAYPAL & CASH APP ($NAFPAorg).
Completed applications and money orders/checks can be mailed to:
Natl African American Families First/Prs
4500 Cass Ave Apt 622
Detroit, MI 48201-1282