Rotarian Registration

Salutation (required)

First Name (required)

Last Name (required)

Email (required)

Phone

Rotary Club Name (required)

Dentist Information (optional)

Dentist First Name

Dentist Last Name

Dentist Email

Dentist Phone

School Information (optional)

School Name

School Contact Email

I would like to help on the following committees:

Organizing Committee

Loot Bag Committee

PR Media Committee

Sponsor Committee

Telephoning Committee

For more information, contact us at: jennifer@brushamania.ca