ROTARY CLUB OF JEFFERSON CITY’s 
STUDENT GOVERNMENT DAY 
April 16, 2013 


REGISTRATION FORM 

____________ YES, the __________________________ Rotary Club plans to 
attend Student Government Day. 
________ Number of Chaperones attending 
________ Number of Students attending 
________ TOTAL attending X $13.00 per person = $_______ 
(Make checks payable to the Rotary Club of Jefferson City) 
Contact Information for the Club’s Lead Chaperone (include email & phone number): 

Your Missouri House Representative is _______________________ 
Your Missouri State Senator is ______________________________ 
We will take the opportunity to notify your Representative and Senator that you will be touring the 


Capitol on April 16, 2013 and provide them an agenda so they can plan accordingly. 


RETURN REGISTRATION FORM ALONG WITH PROPER PAYMENT BY APRIL 10, 2013 TO: 

Arvids “Arv” Petersons 
Rotary Club of Jefferson City 
c/o HSG 
4700 Country Club Drive 
Jefferson City, MO 65109 

Or 

Facsimile: 573-893-3748 

NOTE: It is imperative that the number attending be received on time - we must make 
arrangements and guarantee the lunch. Payments may be brought the day of the event. 
Thanks for your cooperation. 

Please call Arv Petersons, cell 573-680-5670, if you have any questions.