Membership Application

All prospective members of BLM Upstate NY are required to complete this registration form. Please write legibly.

Member Contact information:

Name ______________________________________________________

Date of Birth ___________________

Pronoun _______________

Phone ________________________

Town/City __________________

Email _______________________________________________________

Preferred method of contact:

Text
Email

Call

Social Media

Other ____

General Questions:
1) Are you or were you ever a member of law enforcement?
a.

YES

NO

Are you in regular contact with law enforcement in an official capacity? YES

NO

2) How long have you been in the area?

3) What current members of BLM are you acquainted with?

4) How did you hear about BLM Upstate NY?

5) What issues of social justice are you most interested in? (i.e food justice, youth empowerment, education, police violence,
cultural/arts activism, etc.)

6) What do you hope to learn more about?

7) What skills, talents and resources do you have that you may be willing to lend to this work?

8) What does freedom/liberation/justice look like to you?

Membership Application
Membership:
One-Time Initial Membership and Application Processing Fee (In the event that your membership is not approved this
fee will be refunded in full): $25.00
Method of Payment (please do not mail cash):
Check1

Cash

T-Shirt Size (Mens T-shirt)

Online Payment
S

XL

2XL

3XL

4XL

5XL

Active members of BLMUNY are required to commit to a monthly membership contribution. This monthly contribution
consists of a minimum of three (3) hours BLM related work AND a $10 membership due.

When are you available?

Mark with an X below

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Morning
(8a-11p)
Midday
(11a-12p)
Afternoon
(12p-6p)
Evening/night
(6p & later)

I am interested in doing these tactics (circle as many as you want, you rabble-rouser):
Sit-ins street theater highway shut-downs civil disobedience/ getting arrested flash mobs banner
drops flyering art bombing marching chaining ourselves to things occupation citizens arrest
media-jack/hack infiltration guerilla projectors petitions and creative petition delivery creative
disruption vigils blockade other __________________________

Make Checks payable to Clyanna Lightbourn, Treasurer. Write BLM Membership in the memo

Membership Application

Permission to Use Photographic Images:

Photographs of BLM Upstate NY members may be used in various BLM Upstate NY communications including the
newsletter and on social media. Group photographs taken at BLM Upstate NY events may be used without identifying
individual members. For individual photographs, please indicate your permission for use:
_____ BLM Upstate NY has my permission to use and identify photographs of me.
_____ BLM Upstate NY does not have permission to use and identify photographs of me.
_____ BLM Upstate NY must contact me before using any identified photographs of me in BLM Upstate NY
communications.

I certify that all of the information above is to the best of my knowledge and belief true, correct and complete. I
understand that this information will be used to determine my eligibility for membership to BLM Upstate NY and if
found at time of processing or later that any false information has been given, my membership will be revoked and my
application will be returned to me.
Signature ________________________________________________________

Date ________________

Membership Application

Send completed membership form to:

Social Justice Center
Attn: BLM Upstate NY
33 Central Ave, Albany, NY 12210
Or fill out form electronically and email to:
BLMUpstateNY@gmail.com

Stay In Touch!
www.BLMUpstateNY.com
BLMUpstateNY@Gmail.com
www.Facebook.com/BLMUpstateNY
www.Twitter.com/BLMUpstateNY
www.BLMUpstateNY.tumblr.com
www.Instagram.com/BLMUpstateNY
(518) 545-4016

BLM Official Use only

Membership Application Received ______________
Membership Due Received ______________
Interviewed by ___________________________
Decision

Yes

No

Membership Start Date ___________________________