Payment Voucher

Rotary District 5100

Youth Protection Policy

Payment Voucher

Volunteer’s Name: ____________________________________________________________


City, State, Zip: _______________________________________________________________

Volunteer with Rotary Club of __________________________________________

District 5100’s Youth Protection Policy requires background checks for all volunteers involved with Youth Service Programs. This background check is for one or more of the following purposes of: (check all that apply)

r Youth Exchange

r District Committee Members

r Club Youth Service Programs*

If you checked the Club Youth Service Programs box there is a $12.50 processing fee, therefore, this payment voucher needs to be completed and faxed separately to the Rotary District 5100 office (503) 513-9213. To pay by credit card please complete the following:

Card Type: qVisa qMasterCard qAmerican Express qDiscover

Card Number: ________________________________________________________________

Expiration Date: ___________


Cardholders Name: ____________________________________________________________

Billing Address, City, State, Zip (if different than above):



Signature Date



*Per Dick Elixman, please bill East Portland Rotary Club and mail to:

Walt Harwood


East Portland Rotary Club

804 N. Alberta St.

Portland, OR 97217