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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

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