First Name & Initial |
Last Name |
Rotary District Number |
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I like to be called: |
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Street Address: |
City, State |
Zip Code |
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Phone |
Email |
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I am an out-going Scholar studying abroad.-->
(Please fill in the following: Country/Year.
Example: Holland/2007-08) |
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I am an in-coming Scholar studying at -->
(Please fill in the following: University/Country/District
University in USA, Country of origin, District in home country) |
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I am an Alumnus/a -->
(Please fill in the following: Country/Year) |
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I am a Rotarian Counselor -->
(Please fill in the following: Club/Scholar last name) |
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I am a Rotarian I am a Guest |
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I am a Male I am a Female (for room assignment) |
Registration Package includes registration fee, room (double occupancy), and four meals.
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$ 120 Out-going, In-coming Scholar (will be paid by District) |
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$ 100 Rotarian Counselor, Rotarian, Guest |
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$ 0 Faculty, Alumnus/a |
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Hotel Room Reservation & Additional Comments: |
Reservations will be made for Friday night December 12 for all registrants. Should additional reservations or alternate arrangements be desired, please enter necessary information in the comments field below.
Comments:
Do you have special needs? Is there any issue the form did not cover? Please enter that information in the entry field below.
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Make checks payable to Timothy Forde (please write Rotary Seminar on memo line).
Mail check to:
Dr. Timothy Forde, District 6780
121 FallBerry St.
Oak Ridge, TN 37830
Phone: 865-771-0092
e-mail: fordetb@yahoo.com |
