ENTER THE NAME OF YOUR ROTARY CLUB:
Name of Original Student *
Name of Original Student
Name of substitute student *
Name of substitute student
Student Phone # *
Student Phone #
Provide Student Cell Phone #
Complete Mailing Address *
Complete Mailing Address
Student Date of Birth *
Student Date of Birth
Parent Name *
Parent Name
Parent Emergency Phone Number *
Parent Emergency Phone Number
Health Information
Checkbox *
Date Signed *
Date Signed
Please mail to: Cathy Libey 7283 E. South Shore Drive Hartsburg, MO 65039 Or scan and email to clibey@live.com