2024 Mid-Island Club Founders' Day Registration Form

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Please complete the form

Email *

Full Name (First Name, Middle Name, Last Name) *

Mailing Address *

Telephone Number *

Email Address *

If applicable, Title and Organization *

Have you ever attended any Mid-Island Club Founders' Day Luncheon? *

Yes

Number of Tickets that you are purchasing

$100.00 per Adult

$35.00 per Child (Ages 3-18)

Please list your full name first and then your guests full name. *

Are you receiving an award at the 2024 Mid-Island Club Founders' Day Luncheon? If yes, please list the award.

If applicable, please list the name of the Mid-Island Club Member or Awardee/Honoree that you purchased your ticket from.

If you were provided a ticket number from one of our Club Sisters, please list the ticket number.

If you are a guest of one of the Honorees, Awardees, or Scholarship Recipient, please list his/her name. *

How are you paying for your tickets? *

Cash (please contact Ms. Gerardy Carrenard gacarrenard@gmail.com)

Check (Please mail to Mid-Island Club P. O. BOX 349 Central Islip, NY 11722)

Eventbrite

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

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