Circle K DCON Registration Form

READ CAREFULLY:

  • The FINAL DEADLINE for submission of all Convention Registration Forms is February 8, 2023.
  • The Registration Fee is $40.00 ($50.00 if submitted after February 1st) per person. 
  • Individual Circle K Member registration forms will not be processed until the District Office receives the properly completed and signed KIWANIS RESPONSIBILITY FORM for their home club.

Circle K DCON Registration

Name(Required)
Address
Member of:(Required)

Medical Information & Code of Conduct Agreement

Every Circle K and Key Club member attending DCON is required to properly complete the medical information below and acknowledge they have read, understand, and agree to abide by the Convention Code of Conduct. Kiwanians and other adults do not have to complete this portion.
Emergency Contact
Family Doctor
Do you normally carry a Medical Insurance Card in your possession?
Are you taking any medications?
Are you allergic to any medications?
I hereby certify the medical information above is accurate to the best of my knowledge. I have read the CONVENTION CODE OF CONDUCT and understand compliance with these rules is required at all times during the convention. I also understand that a violation of any of these rules may result in being sent home at my own expense.

Payment

Full refunds are available with written cancelation until February 1, 2023. 50% refunds are available with written cancelation from February 1, 2023 until February 17, 2023. No refunds will be available after February 17, 2023.

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