Rotaract Member Registration Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
How did you hear about us?
Please Select
Social Media
An Event
A Friend
Other
Profession/Work/Area of Study
Membership Dues can be invoiced quarterly or yearly. What would you prefer?
*
Quarterly ($30.50/quarter)
Yearly ($122.00/year)
How Do You Plan on Attending Meetings
In-Person
Virtually
Hybrid (Combo of In-Person + Virtual)
Please Select What Elements of Rotaract You're Interested (choose all that apply)
Bi-Weekly Regular Meetings
On-Call Volunteer Squad
Fundraising Event Planning
Networking
Fellowship
Other
Submit
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