1. Full Name:
First Middle Last
Local Contact Information:
Email: Phone Number: (____)____-______
Include area code!
Year: FR SO JR SR+ Major:
Birthday: Sex: Where are you
F M you from?
Emergency Contact Information: Carpool Information:
Name of Contact: Do you have a car? Yes No
Phone:
Would you be willing
Relationship: to drive to events? Yes No
Family Interests:
Are you interested in being a part of one of our five families?
Yes, I d like to be a Part of a family! No, I do not wish to be in a family!
Membership:
How did you hear about Circle K?
Have you been in a Kiwanis organization before? (i.e. KEY Club)
I am enclosing $30 for my membership dues which includes a T-Shirt of the following size:
Small Medium Large Extra-Large
By submitting this contract, I verify that I am a member of Circle K International, and I will abide by the rules
and regulations of our organization.
Member Signature: __________________________________________ Date Paid: __________________
For Official Use Only:
President Signature: _____________________________ Treasurer Signature: _____________________________
Secretary Signature: _____________________________ Family:_________________ Approval Date: __________