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Polar Bear Swim - Registration Form
Please complete the following form to register for Rotary Club of South East Nassau's Polar Bear Swim on Wednesday 10th January 2024 (12pm start) at Jaws Beach.
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Registration Form
Full Name
*
Your answer
Date Of Birth
MM
/
DD
/
YYYY
E-mail Address
*
Your answer
Telephone Number
Your answer
Which of the following best describes you?
*
Member of a Rotary Club
Member of Rotaract
Member of Interact
Member of Early Act Club
Friend or family of a Rotary Member.
None of the above.
Other:
Required
If you are a member of a Rotary, Rotaract, Interact or Early Act Club, please enter the name of your Club below.
Your answer
If you hold any position (Director, Chair, etc.) within Rotary, please state this below.
Your answer
What is your fundraising target?
*
$25 (minimum)
$100
$500
$1,000
$2,500
$5,000
$10,000
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