Kiwanis Eastern Canada and Caribbean

In order to administer your correct status and your ribbons, would each Kiwanian please register separately.

First Name

Last Name

Highest achieved office

Are You... (Please check all that apply)

Please contact our District Office to register as a voting Kiwanis Delegate? (613-727-0107)

Are you a current LG who will be serving as your Division's LG next year as well?

Are you a First Timer?

Are you a KI Life Member?

Are you a recipient of a KF of Canada Mel Osborne?

Are you inscribed on the Tablet of Honour?

Are you a recipient of a KIF George F. Hixson Award?

Are you a recipient of a KFJ Godfrey Dyer Award?

Are you a Past Governor?

Are you a Past Lt. Governor?

Are you a District Committee Chair?

Are you going to need a headset for simultaneous interpretation in English or French?

Club Name

Kiwanis Club of

Division #

Mailing Address

City

Province

Postal Code

Country

Telephone (Home)

Telephone (Work)

Email Address


If you will be registering a Guest please enter your guest's name so that we can prepare a name badge.

Guest's Name: First	Last	My Guest is a Kiwanian
Names of Additional Guests:	(please separate each additional name with a comma)

Special Food / Physical Requirements

If you will be registering children (16 and under) for our youth program, please tell us their names, ages and T-Shirt sizes:

Name

Age

T-Shirt Size

Name

Age

T-Shirt Size

Name

Age

T-Shirt Size

Name

Age

T-Shirt Size

Adult T-Shirt Size

Registration Fees

	Pre-paid by June 1	Pre-Paid By Aug 1	Onsite Registration	Number	Total
Kiwanian	$275	$295	$310		$
Guest	$180	$200	$210		$
Children (16 & under)	$75	$75	$80		$
Caribbean / Quebec Cruise - Dinner	$55	$55	$55		$
Celebration Breakfast	$10	$10	$10		$
Grand Total					$

Credit Card Information

Name on Credit Card

VISA

Mastercard

Card Number

(Please enter only numbers: no spaces or "-". Thank you.)

Expiry Date

(MM/YY)