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West Coast Regional Rotary International Ambassadorial Scholar Orientation Registration Form
First Name:
Last Name:
Name To Put On Badge:
Address:
City:
State:
    Zip Code:
Email:
Preferred Phone #:
Rotary Club / Sponsor Club
District Number
 
Please Check Below All That Apply To You:
Ambassadorial Scholar Outbound Country To:  
Ambassadorial Scholar Inbound Country From:  
Ambassadorial Sponsor Ambassadorial Alumni
Ambassadorial Sponsor PDG AG
GSE Team Outbound Country To:  
GSE Team Leader Rotarian
DGN DG DGE
Host Counselor AG Speaker
Spouse Other (Please specify)
 
The Registration Fee is $75.00 per person
Friday Dinner, Saturday Breakfast, Lunch, and Afternoon Snack are included. I would like to pay $75 for my registration only.

I would like to pay $85 for my registration, plus a copy of Syndi Seid's book, "Etiquette in Minutes".
I would like to pay $45 for the Friday evening dinner only, plus a copy of Syndi Seid's book, "Etiquette in Minutes". (Extra copies of Syndi Seid's book may be purchased at event for $10 each, while supplies last).

If Paying By Check, Please Make Check out to: Rotary District 5150 ( West Coast Regional
Ambassadorial Training)
Mail To: Steve Wright, Registrar, 1294 Aspen, Pacifica, CA 94044

Paying By:       
Friday Night Meal Request:      
Special Dietary Requests:      Wheat Free   Dairy Free   Gluten Free

I request and authorize my e-mail address to be shared with other attendees at this training session

Please Make Your Hotel Reservation Through The Hotel
The Doubletree/Hilton Hotel, 2050 Gateway Place, San Jose, CA 95110
408-453-4000