FACILITATOR APPLICATION

FACILITATOR INFORMATION

1. Please fill out the form completely and click the "Submit" button.
2. You must print out the form that follows to complete the application process.
3. Get all signatures as indicated on the printed application.
4. Return the original, fully signed, application to Paul Pierce, P.O. Box 235080, Encinitas, CA 92023-5080.

Last Name: *

First Name: *

Middle Initial: *

Name You Like to be Called: *

Birth Date: *

Gender: *

Home Address: *

City: *

State: *

Zip: *

Home Phone: *

Work Phone: *

Mobile:

E-mail Address: *

Rotary Club of: *

T-Shirt Size: *

In Club Budget: *

Former Facilitator: *

Yes

If yes:

(Hold Ctrl/Cmd to select multiple options)

Year(s):

District 5340 Youth Volunteer Affidavit?: *

Willing to be a Bus Chaperone?: *

Previous Experience Working with Youth?: *

Youth Experience Details: *

YOU MUST CLICK ON SUBMIT, PRINT OUT THE FORM THAT FOLLOWS, GET ALL SIGNATURES, AND SEND THE COMPLETED FORM TO PAUL PIERCE, P.O. BOX 235080, ENCINITAS, CA 92023-5080 TO COMPLETE YOUR APPLICATION PROCESS.

FACILITATOR APPLICATION

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