Polar Bear Swim - Registration Form
Please complete the following form to register for Rotary Club of South East Nassau's Polar Bear Swim on Monday 10th January 2022 (12pm start) at Jaws Beach.
Sign in to Google to save your progress. Learn more
Registration Form
Full Name *
Date Of Birth
MM
/
DD
/
YYYY
E-mail Address *
Telephone Number
Which of the following best describes you? *
Required
If you are a member of a Rotary, Rotaract, Interact or Early Act Club, please enter the name of your Club below.
If you hold any position (Director, Chair, etc.) within Rotary, please state this below.
What is your fundraising target? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy