HHART Registration Order Number Your Contact Details First Name * Last Name * Email Address * Primary Phone * Alternative Phone Date of Birth (YYYY-MM-DD) * City * Province * – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Country * Occupation / Special Skills * Are you a member of Rotary? * No Yes, Rotarian Yes, Rotaractor Yes, Other If you are in Rotary, which club? Emergency Contact Information Name * Relationship * Main Phone * Alternative Phone Additional Information Tell us a little about yourself (100-120 words) For Example: HHART Chief of Operations is Steve Wallace. Steve planned this and all previous HHART missions and will guide your team safely through a service trip-of-a-lifetime. Steve is very familiar with the people and villages we will be serving. His experience as a mission planner and team leader was obtained through 24 years of service in the Canadian Air Force. Professionally, Steve is a commercial airline pilot. He is also a Rotarian and past- president of the Rotary Club of Wasaga Beach and past chairman of Rotary International District 7010’s Service Projects Committee. Steve resides in Wasaga Beach with his trusty dog, Buster. Please upload a passport style photo of yourself (JPG and PDF formats only) Hotel info Occupancy Options Single Occupancy Double Occupancy, 2 Double Beds Double Occupancy, 1 King Bed Indicate name of preferred room-mate ( if applicable) Inbound Flight Info Airline * Flight Number: * Flight Date * Flight Arrival Time: * Outbound (home) Flight Info Airline * Flight Number: * Flight Date * Flight Departurel Time: *
