2021-22 Arizona District Registration Form
1st Quarter Registration - November 6 2021

NOTE: Deadline for group rate at hotel is October 29th. Yuma has very few available rooms in the area during this time so there may not be rooms available if you try to book on your own after this date.
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Email *
Full Name *
Phone # *
Club Name *
Is this your first Arizona District Conference? *
How many Member registrations - ($10)? *
Additional Member names
How many Guest Registrations ($5)? *
Guest names
Are you a veteran?
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How many Shrimp Scampi lunches ($15)? *
How many Chicken Parmigiana lunches ($15)? *
Notes/Special Needs
How many will attend the Progressive Dinner (answer each element)? *
Appetizers @ Famous Dave's
Dinner @ Red Lobster
Dessert @ Parad-ice (rolled ice cream)
Payment Information
If paying by credit card, use the following URL (copy and paste into your browser). Don't forget to add the $3 credit card processing fee.


A copy of your responses will be emailed to the address you provided.
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