21st Great Plains Lions Leadership Institute

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NOTE: Course payment needs to be sent to PID Gary Fry, PO Box 606, Mitchellville, IA 50169. Questions concerning GPLLI should be address to PCC Hans Neidhardt, Registrar/Curriculum Coordinator, 7400 NW Ayr Road, Potwin, Kansas 67123, (316) 435-2800, hnwizardofoz@gmail.com.

Email *

Last Name *

First Name *

Middle Initial *

Street/PO Box Address *

City *

State *

Zip Code *

Please enter your 10 digit Cell Phone Number (requested format, example 123-456-7890) *

Email Address *

Home Club *

Sub District Number *

Lion Membership Number *

If requesting to room with another attendee, please provide the first and last name of the Lion.

Special specific requests

Diabetic Diet

Vegitarian Diet

Vegan Diet

Wheelchair Access

Vision Impaired

Hearing Impaired

Other Mobility Challenges

Please provide information for any specific accommodations needed.

Emergency Contact Name *

Relationship to Emergency Contact Name *

Emergency Contact Home Phone *

Emergency Contact Cell Phone *

Emergency Contact Work Phone

Provide any specific medical information that would need to be shared with emergency responders. *

A copy of your responses will be emailed to the address you provided.

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