REGL Residential Program

Congratulations on being selected to participate in the Rotary District 5190 Eighth Grade Leadership program.

To register, please enter all information below. Use the tab key to move between fields.

Click the "Submit" once when finished.

School	*
Student First Name (as you want it printed)	*
Student Last Name	*
Gender (M/F)	*
Street Address	*
City	*
State	*
ZIP	*
Student Home or Cell Phone	*
Student Email (no school email please)
Adult T-Shirt Size	*
Parent's Name	*
Parent's Home Phone	*
Parent's Cell
Parent's Email
Student Dietary Needs
Student Medical Conditions & Prescriptions