Name:*

First Last

Club Name:*

Sponsor Club Name:*

Youth/Adult*

Club Office/Advisor/Chaperone:*

Specify Club Office if Other:

District Office:

International Office:

Email:*

Phone:*

Iowa JOI t-shirt

Registration fee is $40 and will include Lunch, snacks, drawstring bag and a JOI t-shirt. No refunds – you may substitute.

Will pay by check via:*

Please mail to Barb Robertson at 505 North Street, Underwood, IA 51576. Make Checks Payable to Iowa District Optimists

Special requests (vegan, allergies, etc):

Name of Chaperone:*

First Last

1 Chaperone per every 6 members.

Emergency Contact:*

First Last

Emergency Contact Relation:*

Emergency Contact Phone:*

Iowa JOI Convention Registration

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