Rotary Satellite Club of Bluffton Evening Member Application Form
Complete one information form for each satellite club member. One-Time Initial Membership fee $75.00 Quarterly ongoing fee $55.00
Complete one information form for each satellite club member.
The personal data you provide on this form will be shared with Rotary International and The Rotary Foundation (collectively, "Rotary"), and the club's Rotary district and its leaders. The personal data you share with Rotary will be used only for official Rotary business, which includes inviting you to participate in other membership opportunities, communicating key organizational messages, and responding to your questions. Personal data collected by Rotary on this form is subject to Rotary's privacy policy. (https://my.rotary.org/en/privacy-policy)
Full Name
*
Title (Mr., Ms.,Rev., etc.)
First Name
Middle Name
Last Name
Suffix
Occupation (for nametag)
*
Gender?
Female
Male
Prefer to self-describe
Prefer not to share
Date of Birth
*
-
Month
-
Day
Year
Date
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What Rotary member referred/sponsored you?
Are you a current or former member of another Rotary or Rotaract club?
No
Yes
If Yes, Rotary member ID Number
*
if unknown, enter 0
If Yes, Name of former or current Rotary or Rotaract club
Home Phone
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Preferred Phone Number
*
Home
Mobile
Work
E-mail
*
example@example.com
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Mailing Address
(check one)
*
Residence
Business
PO Box
Other
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*If post office box, please provide an alternate address for courier delivery
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select one magazine:
*
Rotary regional magazine
Rotary Magazine (digital)
Rotary Magazine (print)
What size t-shirt would you like?
*
Please Select
X-Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
***Unisex***
Please upload a headshot or picture you would like on your profile. You can also email Karin at the confirmation email with your picture after the submission.
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