Tell us about your organization\cause
Let's get some more info...
Date
-
Month
-
Day
Year
Date
Your Name
First Name
Last Name
Organization
Summary of Your Needs
Organization Contact Name
First Name
Last Name
Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone
Please enter a valid phone number.
Organization Website
Contact Email
example@example.com
How are you involved with them?
As a volunteer
As an employee or agent
No, I am not
Is the organization "Not for Profit? (501.c.3)"
Yes
No
Not Sure
Other
If other, please describe:
What will the funds be used for?
Operating Expenses
Purchase of equipment
Programming
Other
If other, please describe:
Are there branding or publicity opportunities for our Rotary Club?
Yes
No
Are you interested in a corporate or personal membership with our club?
Yes
No
How many years has the organization been in existence (estimates are ok)?
What is your geographic area of focus (check all that apply)?
West Hartford
Hartford County
State of Connecticut
National and International
Other
Rotary International emphasizes the following areas of focus. Please check the boxes that are appropriate to your organization:
Peace and Conflict Resolution
Disease Prevention and Treatment
Water and Sanitation
Maternal and Child Health
Basic Education and Literacy
Economic and Community Development
Protecting the Environment
Urgency (1-5 with 5 being immediately)
Within one year
1
2
3
4
Need Immediately
5
1 is Within one year, 5 is Need Immediately
Are you already involved in Rotary?
Yes
No
in the past
If yes, let us know how and where!
Can we get your members involved with Rotary?
Yes
No
Maybe
If yes, how can they get involved?
Can our members participate in your program(s)?
Yes
No
Submit
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