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All of the data below is required before form is submitted.
PERSONAL
 INFORMATION
First Name Last Name
Parents Name Sex (M/F)
Age Parents Phone (Day)
Parents Phone (Night) Phone (Alternate)
Street Address City
State Zip
Name for Badge E-mail Address
T-Shirt Size (S / M / L / XL/XXL)
ROTARIAN
INFORMATION
Rotary Club of
Rotarian Sponsor Phone (Day)
Phone (Night) Street Address
City
State  
 Zip 
E-mail Address

           NEXT  -  Press the "Check Form Entries" below.

  
                 

            NEXT -  If check is OK Submit your form.

  
              
Please send $350.00 per person Non-refundable payment to:

Charles Johnson
South Georgia College
100 West College Park Drive
Douglas, GA 31533
(912) 260-4338  Fax (912) 260-4456
cjohnson@sgc.edu
www.sgc.edu