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FACILITATOR APPLICATION

LEADERSHIP, ETHICS AND
DETERMINATION
(LEAD) CONFERENCE
September 24 & 25, 2011

FACILITATOR INFORMATION

Please fill out the form completely and click the "Submit" button. You will receive a confirmation screen that the form was sent.

Last Name: *

First Name: *

Middle Initial: *

Name You Like to be Called: *

Gender: *

Male

Female

Home Address: *

City: *

Zip: *

Home Phone: *

Work Phone: *

E-mail Address: *

Men's Shirt Size: *

S

M

L

XL

XXL

Rotary Club of: *

Former Facilitator: *

Yes

No

If yes:

LEAD

RYLA

Year(s):

Certified by District 5340 to participate in youth programs: *

Yes

No

Don't know

Prior Experience Working with Youth: *

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136 days since 2011 LEAD Conference.

Service Above Self
Paul E. Pierce, Jr., LEAD Chair • Rotary District 5340 LEAD Committee • PO Box 235080 • Encinitas, CA 92023-5080
(760) 942-9911 • paul@peplaw.com
Copyright © 2010 Rotary District 5340 LEAD Committee. All rights reserved.

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