Registration Form

Please provide the following information:

First Name

Last Name

Middle Initial

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

Sponsorship Level:

I would like to be added to a foursome.

If you answered "No" to the question above, please enter the name of
Player #2 in the space provided below.

Please enter the name of Player #3 in the space provided below.

Please enter the name of Player #4 in the space provided below.

Please print and send this form along with check made payable to:
La Jolla Rotary Foundation, a 501(c) 3 charity
P.O. Box 525
La Jolla, CA 92038
MEMO: Rotary Youth Scholars Fund
* If you would like to pay by credit card, send us an email and a member
from The Rotary Club of La Jolla will contact you to process payment.

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail