Rotary International District 9640

Please complete the following details and submit by Friday, 19th February, 2010. The details should be sent as soon as possible to have a better chance of representing your preferred country
Registration fee $225.00 per team
All fields marked with an * must be filled
School		*
Sponsoring Rotary Club		*
Team
Student No. 1 Details
	Name
	Age
	Address 1
	Address 2
	Town
	Postcode
Student No. 2 Details
	Name
	Age
	Address 1
	Address 2
	Town
	Postcode
Student No. 3 Details (or International Exchange Student).
	Name
	Age
	Address 1
	Address 2
	Town
	Postcode
Nominated Country
	Preference 1
	Preference 2
	Preference 3
	Preference 4
Form Completed by		School Representative Rotary Youth Director Rotary Club Member
	Name
	Address 1
	Address 2
	Town
	Postcode
	Phone	Please include Area Code
	Fax	Please include Area Code
	E-Mail Address	*
After submitting the form you will be presented with a details page to print out and post to D9640 MUNA