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 Name Last Name
Birth Date:

Month Day Year
Name of Spouse/Significant Other

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

Yes No
If yes, name of club & location:
E-Mail Contact Info
Home E-mail
Work E-mail
Preferred E-Mail Address

Home Work
Phone Contact Info
Home Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Mobile Phone Number:

Area Code Phone Number
Home & Work Address
Home Address:

Street Address

Street Address Line 2

City State / Province

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

Street Address

Street Address Line 2

City State / 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 priviledges, 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. *

Yes No
Application Date

Month Day Year
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
Should be Empty:

Membership Application