Michigan District of Key Club

Conference Registration

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"*" indicates required fields

Participant Name*

First Last

Participant Address*

Street Address Address Line 2 City State ZIP Code

Participant Phone*

Participant Email*

Participant Type*

Student

Adult

Advisor's Email*

Adult Role(s)

Faculty Advisor

Kiwanis Advisor

Parent

Kiwanian

Circle K

Other

Key Club of ...

Kiwanis Club of ...

Circle K of ...

Child's Name

Other role at convention:

Club officer?

Yes

Officer Role

I am a ...*

First Timer

Returning Participant

Shirt Size*

Grade*

Dietary Restrictions

Leave blank if none

Adult Participant Information

There must be at least one adult chaperone for every ten Key Clubbers in attendance. Any advisor/chaperone must remain in attendance for the conference duration; chaperone responsibilities may not be transferred between individuals over the course of the three-day event. All chaperones and adults in attendance must have a valid background check on file per Kiwanis International guidelines.

Criminal History Background Check*

I have a Background Check on file with Kiwanis International.

I do not have a Background Check on file with Kiwanis International.

Chaperone Name*

First Last

Chaperone Phone*

Chaperone Email*

Registration Fee

Registration includes 5 meals, T-shirt and pin. Hotel room is not included; see event information to reserve your room(s).

Registration Fee Options*

Paying for my fee only with my registration

Paying for multiple participants with my registration

Registering only - payment will be with other registration

Registering only - mailing check

Registration Fee

Price:

Quantity

Discount Code

If you have been given a discount code, enter it here.

Total

Participants Paid

List all participant names, one per field. Add fields as needed.

Name of person paying registration

Check from...

List the person, school or organization that will be sending the check.

Credit Card

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Phone

This field is for validation purposes and should be left unchanged.

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