Club Membership Registration Form

Membership Application

Complete the form below to apply for membership in our club. Once your application is accepted information provided will be shared with Rotary International, our parent organization.
Your Name*

First NameLast Name
Birth Date

MonthDayYear
Name of Spouse/Significant Other

First NameLast Name
Who is your Rotary sponsor or referral?*
Are you a past member of a Rotary Club?*

YesNo
If yes, name of club & location:
E-Mail Contact Info
Home E-mail
Work E-mail
Preferred E-Mail Address

HomeWork
Phone Contact Info
Mobile Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Preferred Phone Number

MobileWorkHome
Home & Work Address
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name:
Your Position/Title:
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Why are you interested in joining our club?*
Describe your past community and/or volunteer involvement.*
To understand the rights, privileges and responsibilities of membership be sure to review our Frequently Asked Questions for prospective members.
Please confirm that you understand the privileges, responsibilities and financial aspects associated with Rotary membership and agree to promote the ideals of Rotary and comply with the requirements of this Rotary Club.*

YesNo
Application Date

MonthDayYear
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
Should be Empty:

Membership Application