Midwest Advanced Lions Leadership Institute (MALLI)

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NOTE: Course payment needs to be sent to PID Gary Fry, PO Box 606, Mitchellville, IA 50169. Questions concerning MALLI 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 you 10 digit Cell Phone Number (requested format, example 123-456-7890) *

Email Address *

Home Club *

Sub District Number *

Lion Membership Number *

If requesting to be roomed with another attending Lion. please provide that persons first and last name.

Year(s) served as Club President? *

Other Lions Leadership Institutes attended? *

Highest District and or Multiple District office held and when? *

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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