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Living Legacy Pilgrimage Registration

October 19-23, 2022

Please complete one registration form for each person who will be traveling.

Contact Information
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Prefix
First Name
Last Name
Suffix

Please include your FULL FIRST and LAST NAME as you'd like it to appear on your name tag
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

Do you belong to a church, congregation, synagogue, mosque, meeting, or other faith community?

No acronyms please, except for UU
Identity Information

This information is optional but helps us get a sense of who will be joining us so we can provide the best service to you. 

Check all that apply.

Add other racial identities you claim.

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MM/DD/YYYY (01/01/1955). Please include your birth year in order to secure the best rates at museums. Otherwise, we have to pay the full rate for you. Thank you!
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Will you be over 18 years old by October 19, 2022
Parent/Guardian Info

If you are under 18 years old, please include the name and contact information of your parent/guardian. 

Will your parent/guardian be participating on the trip with you?

First Name
Last Name


Lodging and Roommate Preference
How many people will be sharing a room (including you)?

Type full first and last name of each preferred roommate
Medical/Emergency Needs and Information
Please note and describe any additional support you may need during the LLP.
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Please check all the COVID-19 vaccinations you have had to date.

Please upload a copy of your COVID-19 Vaccination card. If you would prefer, you can text a photo of your card to 601-526-1965 or email it to info@livinglegacypilgrimage.org.

If vaccinations are documented on side 2 of your vaccination card, upload that here.
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Identify any life-threatening allergies, including food-allergies

Note any medical needs you have and any special accommodations you need, especially needs in your hotel room.
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Dietary Restrictions

We cannot guarantee that every meal will meet your needs. However, we make every effort to accommodate special dietary restrictions based on health needs. Please check all the types of foods you CANNOT eat.

For example, if you're vegetarian and gluten-free, check "Beef," "Pork," "Chicken," "Fish," "Shellfish," and "Gluten," as the foods you cannot eat.

If you're an omnivore and have no dietary restrictions -- check "I have no dietary restrictions."

Payment Information

Regular rates are in effect as of August 1, 2022.

After you click the Submit Registration button at the bottom of the form, you will be prompted to enter your credit card information. 

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Financial Assistance Fund Donation

We encourage those who are privileged by means of their color or economic advantage to contribute a full or partial registration to our Living Legacy Project Financial Assistance Fund. This amount will allow a person whose life has been impacted by color discrimination, by the legacy of enslavement and/or racism, or through economic disenfranchisement to fully participate in the pilgrimage. All of us will be richer for these reparations.

The value of this Living Legacy Pilgrimage is priceless. By donating toward the cost of the trip, you have an opportunity to take concrete action toward healing the wounds of racism.

ONLY SELECT AN AMOUNT IN THE SECTION BELOW IF YOU WANT TO MAKE AN ADDITIONAL DONATION OVER AND ABOVE YOUR REGISTRATION FEE. 

$
Consents
In order to participate in the Pilgrimage, we ask that you read and agree to our participant agreement, which covers our COVID-19 policy, terms and conditions, and our code of conduct. You can find all this important fine print here: www.livinglegacypilgrimage.org/participantagreement.html.
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I understand that by typing my name in the field below, I am electronically signing the Living Legacy Project Participant Agreement.
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If the registrant is under 18 years old, type the name of parent/guardian as signer.