Date:___________________

Name:___________________________________________

Street Address:_______________________________________________________________________

City: _____________________________________________ State: __________ Zip: _______________

SDUSCT Chapter (if known) ________________________________________________ 

Current Membership No.(if renewal) [________]  E-Mail: ___________________________________  Phone:______________________
 

Individual Annual Membership ............................$25 [    ] Youth(<20) .........................................$15 [    ] Lifetime Membership ..........................$100 [    ] Gold Life ............................................$500 [    ]

S&DUSCT Chapters* Annual Registration ............................... $50 [    ] Lifetime Registration ............................ $250 [    ] * A S&DUSCT Chapter is charted by the African American Civil War Memorial Freedom Foundation with 15 or more members of the S&DUSCT.

Memorial Member .......... [    ]
Name of adopted USCT soldier __________________________________
Please assign me an adopted soldier ..... [    ]

Descendant Member ..........  [    ]

Name of soldier listed on Wall of Honor ________________________________________

Regiment in which soldier served ______________________________________________