Bellevue Breakfast Rotary Club                                                                              Region 2 CA

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5th Annual

Rotary Family Fest

 

Family Registration Form

 

·      Saturday October 20, 2012      11:00 am – 1:00 pm

·      Woodridge Elementary School

12619 SE 20th Pl Bellevue, WA 98005

 

The following family would like to attend the Region 2 Rotary Family Fest Event:

Name (s)      

Address        City        Zip      

Phone         Email      

Family Worker Information:   Family Worker’s Name      

Phone       Email      

Agency      

Address       City         Zip      

Homestudy Approval Date        Is the Family Licensed?       

Does this family consent to be photographed/videotaped         YES           NO

 

Families must be registered by their agency worker and a confirmation will be sent to the family and the agency worker.  Space will be limited to the first 30 families. 

 

Signature                                                                 Date                                                                                                             

                      *signature not required for emailed registration

 

Please send Family Registration forms via email to:

 

Laurie Mayer, MSW laurie.mayer@dshs.wa.gov

Region 2 Office of Adoptions & Permanency Planning

ph. 425.590.3081