Registration Form Request Form | Civitan International

International Headquarters will create a registration form for your district event or program. To do so, please complete the details your form will need below. Any funds received in association with a district registration form will be credited to the district’s budget.

Once submitted, please allow up to 7 business days for your form to be created. With any questions, please contact Priscilla Denard at priscilla@civitan.org.

Region Online Registration Form Request

Name of Person Requesting Form(Required)

First Last

Email of Person Requesting Form(Required)

Name of Registration Event(Required)

What event or program are you creating a form for?

Event/Program Start Date

Event/Program End Date

Event/Program Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Registration Deadline(Required)

Registration Cost(Required)

Registration Cost (Additional cost besides the above)

Registration Minimum

Registration Maximum

What information do you need from attendees?(Required)

Club Name

T-Shirt Size

Dietary Restrictions

Other

No information needed

If "other" above, please describe

Who from the region should receive registration confirmation emails?(Required)

Please include name and email address of each person

What budget line item should fees from this event/program be credited to?(Required)

District Budget, All-In Summit, etc.

Are there any other details or questions you need to include on this page or form?