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To become a member please print the following forms, complete and mail it with your membership donation (money order please) to either your local chapter or national headquarters. Yearly donation suggestions: $50 family; $25 single, $12.50 student

A Place For Us Membership Form Yes, keep me up to date with A Place For Us! Last Name:_____________________ His First:: __________Her First : _____________ Phone: (____) _______________    Cell: (____)  ________________ Address: ________________________________________________ City: ____________________________  State: _____  Zip: _______ E_mail: ________________________________@_______________ How did you hear about A Place For Us: _______________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Children Names and ages: __________________________________________________ _______________________________________________________________________________ I would like to volunteer in the following areas: ____  Public Relations  ____  Newsletter   ____  Event Planning   ____  Membership ____  Resources            ___  Web-site     ____   Financial donations only Circle interests:   Discussions    Rallies    Movies     Annual Banquet    Home fellowships    Ministry              Youth outings   Social Activities        Ministry                     Counseling Send tax deductible donation to:

Multi-racial Family Survey You may think we are just plain “nosey”, but from time to time we get calls from the media interested in our “elite” society. Please answer these questions so we can give a somewhat intelligent and slightly statistical answer. Please complete the membership form so we can keep you informed of future events. 1. Which best describes you and/or your immediate family?  Multiracial Adult                       Dating Interracially           Single w/Biracial Children Interracial Married Couple       Transracial Adoption Family Multiracial family                     or  _______________________ 2. Marital Status: Single   Divorced   Married    Widow    How long have you been married?   _______ 3. Husband ‘s race: ________________________________ 4. Wife’s race: ____________________________________ 5. Ages of children and their racial makeup: _________________ __________________________________________________ __________________________________________________ 6. Husband’s family supportive? Yes    or     No 7. Wife’s family supportive? Yes   or    No 8. Have you ever had to hide (or felt like you had to hide) your spouse or your children for fear of rejection or retaliation? On the job, at Church, with your family? Explain. ______________ __________________________________________________ __________________________________________________ __________________________________________________ 9. Have your children had problems with public education dictating their race?    Yes    of     no 10. Are you willing to be interviewed or appear on a live “tasteful” talk show dealing with multiracial issues?   Yes    or      no 11. What do you think is the single most issue multiracial families have? _____________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 13. Comments: ________________________________________ __________________________________________________ __________________________________________________ __________________________________________________