Register

Register for THE ROTARY RETREAT

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Industry/Employment *

Position Title *

Gender (For room assignment purposes.) *

Male Female Transgender Other

Do you have any food allergies or dietary restrictions? If so, please list and explain. *

EMERGENCY CONTACT INFORMATION

Name *

First

Last

Relationship *

Phone Number *

After registering for the Rotary Retreat, please mail your check or money order for $75 to:

Malika Carter - Passion4Pivot
1225 Stanford Rd. #1
Grand Forks, ND 58203

Payments will be processed by Passion4Pivot LLC and must be received by September 22, 2014 to confirm registration.