“Healthy Minds / Healthy Environment”
CREATE HOPE IN THE WORLD
District 5580 Conference 
APRIL 11 - 13, 2024
 
Contact Information
IF BOTH SPOUSES/PARTNERS ARE ROTARIANS, you can complete one (1) on-line registration form and check the "Rotarian" group at the bottom of both columns.
Optional: Do you have a ClubRunner login?
User Name:
Password:
Your Information
First Name:
  
Last Name:
  
First Name for Badge:
Email:
  
District Officer? Please Select:
District Committee Chair? Please select ONE:
Past District Governor?:
Club Name:
Club Officer or Chair? Please select:
Preferred Phone:
Address 1:
Address 2:
City:
Zip/Postal Code:
Country:
State/Province:
Child(ren) Attending: Name(s) and Age(s):
 
Group:









Your Partner/Guest Information
First Name:
Last Name:
First Name for Badge:
Email:
District Officer? Please Select:
District Committee Chair? Please select ONE:
Past District Governor?:
Club Name:
Club Officer or Chair? Please select:
Preferred Phone:
Address 1:
Address 2:
City:
Zip/Postal Code:
Country:
State/Province:
Child(ren) Attending: Name(s) and Age(s):
 
Group:









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