Visions for Success

Success Is A Predetermined Destiny.
SEE the Vision!
PLAN the Vision!
BE the Vision!
Live the Vision!

"Without education, there is no hope for our people and without hope, our future is lost" -Charles Hamilton Houston

Historical Black College Tour

Please print out this form and mail it to the address below.

Date:
First Name:
Last Name:
Date of Birth:
Age:
Sex:
Address:

City:
State:
Zipcode:
Home Phone #:
Cell Phone #:

Mothers Name:
Mothers Cell Phone #:
Fathers Name:
Fathers Cell Phone #:

Emergency Contact #1Name:
Phone #:
E-Mail:

Emergency Contact #2 Name:
Phone #:
E-Mail:

School
Grade:



Student Signature	Parents Signature

Vision for Success (Black College Tours)
P.O. Box 18531 Fairfield, Ohio 45018-0531
Phone: (513) 607-8894 / (513) 604-4782