Full name

Spouse/Partner name (if applicable)

Wedding anniversary (dd/mm/yyyy) (if applicable)

Your email

Phone number

Full Address

Birthdate (dd/mm/yyyy)

Company name

Position/Title

Membership Type
Regular MemberFriends and FamilyHonorary
If a former Rotarian, list Club(s) and Date(s)

Rotary Club anniversary (if applicable)

If you are currently a Rotarian, please include here your Member ID (if applicable)

Why are you interested in joining the Keystone Rotary E-Club?

Please list your hobbies/interests

Please submit a photo of yourself (by submitting a photo you are giving us content to use it on the Keystone Rotary members page)