Club Officers: Requests & Updates

Request Submitted By:*

First Middle Last

Street Address City State ZIP Code

*

If you no longer have a home phone number or do not have a cell phone, please enter N/A in the appropriate field.

Home Phone	Cell Phone	Email

My Club*

My Club Officer Position

Request Information

Information will be emailed to you within two business days.

Please send the following ...

To select more than one option, hold down the Ctrl key (PC) or CMD key (MAC) and click on each applicable choice. In case of an accidental selection, continue to press the Ctrl/CMD key and click on the entry you wish to deselect. When selection is complete, release the Ctrl/CMD key.

Additional Request for Information

Please provide a brief description of your request. Requests for additional information must be submitted for review. After the review process is complete, you will be notified through the email address listed above regarding approval and/or availability of the requested information.

Please consider this request for the following information that falls outside of the options previously listed.

Club/Member Updates

I want to ...

To select more than one option, hold down the Ctrl key (PC) or CMD key (MAC) and click on each applicable choice. In case of an accidental selection, continue to press the Ctrl/CMD key and click on the entry you wish to deselect. When selection is complete, release the Ctrl/CMD key.

Add Member(s)

Quantity of New Members*

Select the number of new members you will be adding. To add more than five, please split the list and repeat the submission process.

New Member #1

First Name	Last Name	Recruited By Name	Recruited By ID#

Date of Birth	Gender	Ethnicity	Spouse's Name

Street	City	State	Zip

Occupation	Home Phone	Cell Phone	Email

New Member #2

First Name	Last Name	Date of Birth	Recruited By

Date of Birth	Gender	Ethnicity	Spouse's Name

Street	City	State	Zip

Occupation	Home Phone	Cell Phone	Email

New Member #3

First Name	Last Name	Date of Birth	Recruited By

Date of Birth	Gender	Ethnicity	Spouse's Name

Street	City	State	Zip

Occupation	Home Phone	Cell Phone	Email

New Member #4

First Name	Last Name	Date of Birth	Recruited By

Date of Birth	Gender	Ethnicity	Spouse's Name

Street	City	State	Zip

Occupation	Home Phone	Cell Phone	Email

New Member #5

First Name	Last Name	Date of Birth	Recruited By

Date of Birth	Gender	Ethnicity	Spouse's Name

Street	City	State	Zip

Occupation	Home Phone	Cell Phone	Email

Delete Member(s)

Please enter all requested information for each individual to be removed from the club's roster. To remove more than one club member, click the small plus sign at the end of the row. A new row will be added for the additional removal.

First Name	Last Name	Street	City	State	Zip

Reason for Deletion*

Date Deceased

If unknown, leave blank.

Update Member(s) Contact Information

Update Member Information

Please enter the new information for each member. To submit changes for more than one club member, click the small plus sign at the end of the row. A new row will be added for the additional information change.

First Name	Last Name	Street	City	State	Zip	Home Phone	Cell Phone	Email

Change Meeting Location

Change Meeting Details

Please enter all requested information to ensure accurate location of meeting location pin on Find A Club map.

Business/Building Proper Name	Full Street Address	City	State	Zip	Meeting Time (please indicate a.m. and p.m.	Meeting date(s)	Meeting Frequency

Untitled

Club Officers: Requests & Updates

Requesting Club Officer

Request Information

Additional Request for Information

Club/Member Updates

Add Member(s)

Delete Member(s)

Update Member(s) Contact Information

Change Meeting Location

Sertoma Success

2015-16 Sertoma Grant Recipient Johns Hopkins All Children’s Hospital (JHACH)

Hearing Health Seminar Inspires in Surprising Ways

Norfolk Sertoma’s Largest Donation Advances Hearing Research