Registration form 2017-18 School Year The information on this form will be shared with Rotary International, The Rotary Club of Abbeville, the Vermilion Interact Participant Club and Affiliates, and the Vermilion Parish School Board. Club dues are $15. Please provide payment when returning this form. Shirts are included in club dues. PERSONAL INFORMATION: SCHOOL: _______________________________________________________________________________________________ STUDENT NAME: _________________________________________________DOB:_____________________ GRADE: _______________ ADDRESS: __________________________________________________________________________________________________________ STUDENT EMAIL: _______________________________________________________________ SHIRT SIZE _______________________ NAME OF MOTHER: ________________________________________________________________________________________________ HOME: __________________________________________________CELL: ____________________________________________________ WORK: ______________________________________ MOTHER EMAIL: ____________________________________________________ NAME OF FATHER: _________________________________________________________________________________________________ HOME: __________________________________________________ CELL: ____________________________________________________ WORK: _________________________________________________ FATHER EMAIL: __________________________________________ ALTERNATE CONTACT: ____________________________________________________________________________________________ HOME: __________________________________________________ CELL: ____________________________________________________ WORK: _________________________________________________

Media Release: Initial One (1) of the Following:

__________ (Initials)

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YES, I hereby GIVE permission to Rotary International, The Rotary Club of Abbeville, or the Vermilion Interact Participant (VIP Club) and its sponsors to publish my child’s photograph and identification, as well as to publish my child’s work or presentations in any of (VIP)’s media-based productions. NO, I hereby REFUSE to give Rotary International, The Rotary Club of Abbeville, or the Vermilion Interact Participant (VIP) and its sponsors permission to publish my child’s photograph, identification, and/or work in any of VIP’s media-based productions, EXCEPT I authorize inclusion of my child’s school photo in the SCHOOL YEARBOOK. NO, I hereby REFUSE to give Rotary International, The Rotary Club of Abbeville, or the Vermilion Interact Participant (VIP) and its sponsors permission to publish my child’s photograph, identification, and/or work in any of VIP’s media-based productions.

Dietary Needs: (vegetarian, allergies, etc.) _____________________________________________________________________ Student Name (print): ______________________________________________

Date: __________________

Student Signature: _________________________________________________ Parent/Guardian Name (print): _______________________________________

Date: __________________

Parent/Guardian Signature: __________________________________________

OFFICE USE ONLY $15 dues Cash ____ Check ____ CK# ________

Please mail all forms and fees to: Vermilion Interact Participants Club P.O. Box 698 - Abbeville, LA 70510

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