Polio Plus Benefit Dinner
Registration Form
Forms and money must be received by close of business on Friday, April 10th.
Title: _____________________________ Name: ____________________________________________________________
(first name)                           (last name)                       
Contact Number: _____________________________  E-mail: _____________________________________________
Mailing Address: _____________________________________________________________________________________
City: _____________________________        State: ___________________         Zip:___________________________
Names of guests and their titles:
Total number of plates to reserve:  ___________     x     $50/plate    =     ____________    (total cost)
Your registration will not be complete until OU Rotaract receives your registration money.
Special food requirements: (allergies, vegetarian, etc.) Please list the guest name that has these requirements.
Registration forms and money are due by April 10th, 2015.
Please make all checks payable to:
OU Rotaract Club, with “PolioPlus Banquet” in the memo line
Completed forms and money may be mailed to:
Dennis Brigham
2211 Westpark Dr.
Norman, OK 73069
The University of Oklahoma is an equal opportunity institution. For accommodations on the basis of disability, or if you have any further questions about the event, please contact rotaract@ou.edu or call (405) 315- 6709.