New England Circle K

Circle K International

Registration

New England District of Circle K

50th Annual District Convention

February 26-28, 2010

ONLINE REGISTRATION FORM

(Note: Payments MUST be mailed separately)

*Register today to save your spot and send in your payment by February 1st*

Fee: $160 per Circle K member for two nights accommodations, four meals and admittance to all Circle K events. The fee does not include incidentals.

Deadline: Registration forms MUST be submitted online by Monday, February 1st, 2010 no later than MIDNIGHT!

Payment : Payment must be postmarked by Monday February 1st, 2010. Checks should be made out to New England Circle K. Please send payment to:

Matt Dellea

Westfield State College

Dickinson Hall CDA

Westfield, MA 01086

Questions: Contact Matt Dellea at mattdellea@gmail.com.

If you are not a member of Circle K International, please use the Registration Form for Non-Members. Thank you!

Part I: Registration Form

*Name *School *Class Year
2010 2011 2012 2013 *Office Held (if any) *Address (Street, City, State, Zip)
*E-mail *Phone *Preferred Roommates (List three with name/school)
Special Diet (if any) Payment Type (i.e. personal check, school check, etc.) *Registrant Agreement:
*Registrant Agreement Signature (please initial) *Date

Part II: Medical Questionnaire/Emergency Medical Treatment Authorization

*Name *Height *Weight *Sex
Male Female *Address (Street, City, State, Zip)
*Emergency Contact Person: *Relationship to you *Emergency Contact Home Phone *Emergency Contact Work Phone *Alternate Emergency Contact Person *Relationshiph to you *Alternate Contact Home Phone *Alternate Contact Work Phone *Doctor's Name *Doctor's Phone *Doctor's Address (Street, City, State, Zip)
*Health Insurance Company *Health Insurance Policy Number Any other pertinent information on card List any medications you will be taking during the weekend Have you been treated for any of the following (Check all that apply)
A. Nervousness
B. Any mental disorder
C. Convulsions or Epilepsy
D. Fainting Spells
E. Heart Condition
F. Rheumatic Fever
G. Cancer or Tumor
H. High Blood Pressure
I. Severe or Frequent Headaches
J. Asthma
K. Ulcers
L. Diabetes
M. Allergic reaction to medication
N. Any other allergies or illnesses?
*Do you have any physical limitations?
Yes No If you answered yes to any of the above questions, please give details of treatments, dates, physicians, hospitals, and clinics below.
*PLEASE READ CAREFULLY (Treatment Agreement)
*Treatment Agreement Signature (Please initial) *Date

Make sure to verify that the above information is correct before you submit this form.
Thank you!