Your Contact Details

First Name

Last Name

Email Address

Primary Phone

Alternative Phone

Date of Birth (YYYY-MM-DD)

City

Province

Country

Occupation / Special Skills

Are you a member of Rotary?

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