REGISTRATION FORM

2016 Rotaract Club of Kandaya

Eastern Visayas State University Chapter

Tacloban City
PLEASE COMPLETE ALL SECTIONS.

REGISTRANT DETAILS
Family Name

First Name

Course

Year & Section

Middle Name/Initial

College

Contact Information Provide your current mailing address. Any changes will be reflected in your member profile.
Address

City

State/Province

Postal Code

Country

Contact Phone (including country and city codes)

Home Phone

Mobile Phone

Home Fax

Email (Required and must be unique. Email address cannot be shared by another club member or club.)

Parent or Guardian Information Contact information for an adult is required for all registrants age 18 or younger.
Parent or guardian information will be used only for contact purposes and does not register the parent or guardian for the convention or any events.
Family Name

First Name

Phone (including country and city codes)

Email

Emergency Contact (required):

Middle Name/Initial

Phone (including country and city codes)

Name

Areas of interest:
Community Service
International Service
Professional Development
Youth Service
Club Service
1. Will you take part in 60% of the clubs social and service activities? Yes No
2. Are you willing to pay member dues?
Yes No
I understand and accept the principles of Rotaract as expressed in its purpose and objectives, and agree to comply with and be bound by
the Standard Rotaract Club Constitution, Rotaract Statement of Policy, and by-laws of the club.

_______________________________________
SIGNATURE OVER PRINTED NAME

Registrant