Black Loyalist Registration Form

The Black Loyalist Heritage Society is committed to Discovering, Preserving and Promoting the history of the Black Loyalist in Canada.

Personal information (this information will be used for registry purposes only)

Family Name:

Given names:

Maiden Name:

Spouse's Name:

Birth date:

Mailing Address:

City, Province:

Postal Code:

Home Telephone:

Work Telephone:

E-mail:

Place of Birth:

Occupation:

Another Family member or I have started a family tree.

I am interested in starting a family tree.

I like the idea of genealogy linking Black Loyalist families.

I Don't like the idea of genealogy linking Black Loyalist families

Enter the names of your Dependent Children and their Birthday in the space provided below: (e.g. John Smith JR Feb. 12 1984)

Enter the names of your Adult Children and their Phone number in the space provided below: (e.g. John Smith JR 705-555-0565 )

The Black Loyalist Heritage Society intends to publish the " First Canadian Black Loyalist Registry ". The Society requests your permission to publish your name and contact information. The Registry will be the first of its kind in Canada. We thank you for your participation.
I hereby give permission to use my name and contact information
I hereby give permission to use just my name and may only use my contact information to contact me personally
I do not give permission to use just my name and may only use my contact information to only contact me personally
Security Code:

Type the Code:

Click Here for a new code.

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Copyright © 2001 Black Loyalists. All rights reserved.

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