All of the * data below is required before form is submitted.

*Rotary Club of:		submits the following  individual as sponsored Awardee for RYLA.
PERSONAL and PARENT INFORMATION
*First Name:	*Last Name:
*Age:	*Sex (M/F):
*Name for Badge:
*T-Shirt Size:	(S / M / L / XL/ XXL)
*Parents Name:
*Phone (Day):
*Parents Phone (Night):
*Mail Address (street, city, ZIP):
E-mail Address:
May we share your name and Rotary  Club sponsor with other attendees?		Yes  No
ROTARIAN  INFORMATION
*Rotarian Sponsor:
*Mail Address (street, city, ZIP) :
*Phone (Day):
*Phone (Night):
E-mail Address:
NEXT  -  If check is OK Submit your form.
Please send $400.00 per person Non-refundable payment to: Charles Johnson South Georgia State College 100 West College Park Drive Douglas, GA 31533 (912) 260-4338  Fax (912) 260-4456 charles.johnson@sgsc.edu www.sgsc.edu