Rotary District 7810 - 2018 Conference

  Beautiful Bathurst, N.B. Canada. - October 19-21    


YOUTH REGISTRATION FORM


ROTARY DISTRICT CONFERENCE


Oct 19-21, 2018 Best Western, Bathurst N.B.


Name _______________________________T-Shirt Adult Size: (circle) XS.  S. M. L.  XL. XXL.


Male ____Female_____ Other ___Cell Phone # ____________________


Age ______   Grade _______   School/College/University __________________


Registration:  $ 70.00 paid by:  Self_______. Sponsor_________. Host Club_________


Member:   Interact ______  Rotaract  _______   YEP______. Other __________


Name of Sponsoring Rotary Club: _____________________________________


Name of ADVISOR associated with above sponsor_________________________


Advisor’s E Mail: __________________________Cell Phone # _______________


Community Activities Involved In:  ______________________________________


__________________________________________________________________


School/ College/University Community Activities Involved In : __________________________________________________________________


Personal Interests (Other than previously mentioned): ______________________


___________________________________________________________________


Medical /Dietary concern/ Physical limitations/ (Epi Pen for? Allergies?) ___________________________________________________________________


Name of ADVISOR / ADULT / PARENT (circle one) travelling with to/from the


Conference:  ________________________________________________________


Driver’s Cell Phone #: ______________________________


Medicare #____________________________________


Parent’s Signature (Interact only) __________________________________


Media Photograph permission (circle one):     yes / no


 


Please return to email slak2@rogers.com


Questions: 506-440-1198/ Susan Kulesza/506-440-1883/ Don McKay