Signed___________________________________________________ _____________________________________
(Applicant) (Print name)
Signed __________________________________________________ ______________________________________
(Father/Guardian) (Print name)
Signed___________________________________________________ ______________________________________
(Mother/Guardian) (Print name)
In the presence of Sponsor
Rotary Club Representative_______________________________________ __________________________________
(Signature) (Print name)
Dated this ____________ Day of ____________________ ___ _____________