District Conference Registration Form | The Rotary Club of Grahamstown Sunset

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DISTRICT CONFERENCE REGISTRATION FORM

29 April to 1 May 2022

Grahamstown, Eastern Cape

Please select an option below:

FULL CONFERENCE
SPEAKERS ONLY
DAY PASS

First Name*
Last Name*
Known As*
Email*
Cell Phone Number*
Home Telephone Number (with dialing code)
Business Telephone Number (with dialing code)
Gender*
- Male
- Female
Meal Preference*
Rotary Club*
Are You a Paul Harris Fellow?*
- Yes
- No
Is this the first time you are attending the conference?*
- Yes
- No
- First Time In-person
What Is Your Conference Status? Please select the option that best describes your position*
Will You Attend the Ann's Lunch?*
- Yes
- No
Will You Attend the Donor's Lunch?*
- Yes
- No
EREY (minimum $26.50)*
- Yes
- No
Are you a PHF Society Member/ Major donor?*
- Yes
- No
Are you a Polio Plus Society Member?*
- Yes
- No
Are You Bringing a Guest/Spouse/Second Delegate?*
- Yes
- No
Details of Your Guest/Spouse/Second Delegate
First Name
Last Name
Known As
Email
Cell Phone Number
Gender
- Male
- Female
Meal Preference
Is Your Guest/Spouse/Second Delegate A Rotarian?
- Yes
- No
Rotary Club*
Are they a Paul Harris Fellow?
- Yes
- No
Is this the first time they are attending the conference?
- Yes
- No
- First Time In-person
What Is Your Guest/Spouse/Second Delegate's Conference Status? Please select the option that best describes their position
Will They Attend the Ann's Lunch?
- Yes
- No
Will They Attend the Donor's Lunch?
- Yes
- No
Is Your Guest/Spouse/Second Delegate a PHF Society Member/ Major donor?
- Yes
- No
Are They a Polio Plus Society Member?
- Yes
- No
Hidden
Section Break
Do You Need a Project Table?*
Will You Provide Your Own Table & Chairs?*
If no, the cost will be R50
I am aware and understand that a R1,090.00 per person conference registration fee is required for registration confirmation.*
- Yes
POPIA CONSENT*
POPIA CONSENT: We will not sell, share or rent your Personal Information to any third party or use your email address for unsolicited mail. Any emails sent by us will only be in connection with the provision of our services and/or the marketing thereof. By clicking the checkbox, you give consent for us to contact you using the information supplied.
- I Agree

First Name*
Last Name*
Known As*
Email*
Cell Phone Number*
Home Telephone Number (with dialing code)
Business Telephone Number (with dialing code)
Gender*
- Male
- Female
Rotary Club*
Are You a Paul Harris Fellow?*
- Yes
- No
Is this the first time you are attending the conference?*
- Yes
- No
- First Time In-person
What Is Your Conference Status? Please select the option that best describes your position*
EREY (minimum $26.50)*
- Yes
- No
Are you a PHF Society Member/ Major donor?*
- Yes
- No
Are you a Polio Plus Society Member?*
- Yes
- No
Which Lectures Would You Like to Attend?*
- Select All
- Two Aspects of Leadership - David Allen - Saturday
- Love your City - Matt Hogiarty - Saturday
- Environment - Turning waste into Money - Lindsay Hopkins - Saturday
- BREAKAWAYS: Conflict & Peace resolution OR Girl Empowerment - These run concurrently
- International Partners & ICC's - Helena Visser (D9350) - Saturday
- Rotaract & Rotary - Nitesh Harry and committee - Saturday
- Environment - Lindsay Hopkins, Tommy Borman & Michelle Hofmeyer - Saturday
- Official address by RIPPR - Per Hoyen - Sunday
- Different Forms of Leadership - David Allen - Sunday
- Current situation in South Africa - Theo Venter - Sunday
- "Empowering the girl child - It starts with me" - Dr Puleng Letsie - Sunday
- Advantage of Coalition - DG Ian Robertson - Sunday
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Section Break
I am aware and understand that there is a R50 per person charge for each selected lecture.*
- Yes
Number of Lectures Selected
POPIA CONSENT*
POPIA CONSENT: We will not sell, share or rent your Personal Information to any third party or use your email address for unsolicited mail. Any emails sent by us will only be in connection with the provision of our services and/or the marketing thereof. By clicking the checkbox, you give consent for us to contact you using the information supplied.
- I Agree

First Name*
Last Name*
Known As*
Email*
Cell Phone Number*
Home Telephone Number (with dialing code)
Business Telephone Number (with dialing code)
Gender*
- Male
- Female
Meal Preference*
Rotary Club*
Are You a Paul Harris Fellow?*
- Yes
- No
Is this the first time you are attending the conference?*
- Yes
- No
- First Time In-person
What Is Your Conference Status? Please select the option that best describes your position*
EREY (minimum $26.50)*
- Yes
- No
Are you a PHF Society Member/ Major donor?*
- Yes
- No
Are you a Polio Plus Society Member?*
- Yes
- No
Are You Bringing a Guest/Spouse/Second Delegate?*
- Yes
- No
Details of Your Guest/Spouse/Second Delegate
First Name
Last Name
Known As
Email
Cell Phone Number
Gender
- Male
- Female
Meal Preference
Is Your Guest/Spouse/Second Delegate A Rotarian?
- Yes
- No
Rotary Club*
Are they a Paul Harris Fellow?
- Yes
- No
Is this the first time they are attending the conference?
- Yes
- No
- First Time In-person
What Is Your Guest/Spouse/Second Delegate's Conference Status? Please select the option that best describes their position
Is Your Guest/Spouse/Second Delegate a PHF Society Member/ Major donor?
- Yes
- No
Are They a Polio Plus Society Member?
- Yes
- No
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Section Break
Which Day Program Would You Like To Attend?*
- Saturday
- Sunday
Would You Like to Attend the Dinners?*
- Yes
- No
Which Dinner Would You Like To Attend?
- Saturday - The Great Gatsby
- Sunday - Houston Comes to Grahamstown
- Both
I am aware and understand that a R390.00 per person day pass fee is required - which includes 2 teas and lunch - for registration confirmation and an additional R200 per person is payable for each dinner.*
- Yes
POPIA CONSENT*
POPIA CONSENT: We will not sell, share or rent your Personal Information to any third party or use your email address for unsolicited mail. Any emails sent by us will only be in connection with the provision of our services and/or the marketing thereof. By clicking the checkbox, you give consent for us to contact you using the information supplied.
- I Agree

First Name*
Last Name*
Known As*
Email*
Cell Phone Number*
Home Telephone Number (with dialing code)
Business Telephone Number (with dialing code)
Gender*
- Male
- Female
Meal Preference*
Rotary Club*
Are You a Paul Harris Fellow?*
- Yes
- No
Is this the first time you are attending the conference?*
- Yes
- No
- First Time In-person
What Is Your Conference Status? Please select the option that best describes your position*
Will You Attend the Ann's Lunch?*
- Yes
- No
Will You Attend the Donor's Lunch?*
- Yes
- No
EREY (minimum $26.50)*
- Yes
- No
Are you a PHF Society Member/ Major donor?*
- Yes
- No
Are you a Polio Plus Society Member?*
- Yes
- No
Are You Bringing a Guest/Spouse/Second Delegate?*
- Yes
- No
Details of Your Guest/Spouse/Second Delegate
First Name
Last Name
Known As
Email
Cell Phone Number
Gender
- Male
- Female
Meal Preference
Is Your Guest/Spouse/Second Delegate A Rotarian?
- Yes
- No
Rotary Club*
Are they a Paul Harris Fellow?
- Yes
- No
Is this the first time they are attending the conference?
- Yes
- No
- First Time In-person
What Is Your Guest/Spouse/Second Delegate's Conference Status? Please select the option that best describes their position
Will They Attend the Ann's Lunch?
- Yes
- No
Will They Attend the Donor's Lunch?
- Yes
- No
Is Your Guest/Spouse/Second Delegate a PHF Society Member/ Major donor?
- Yes
- No
Are They a Polio Plus Society Member?
- Yes
- No
Hidden
Section Break
Do You Need a Project Table?*
Will You Provide Your Own Table & Chairs?*
If no, the cost will be R50
I am aware and understand that a R1,090.00 per person conference registration fee is required for registration confirmation.*
- Yes
POPIA CONSENT*
POPIA CONSENT: We will not sell, share or rent your Personal Information to any third party or use your email address for unsolicited mail. Any emails sent by us will only be in connection with the provision of our services and/or the marketing thereof. By clicking the checkbox, you give consent for us to contact you using the information supplied.
- I Agree