This form is for delegates in Region 5

Club secretaries in Region 2 please provide delegate information by April 4, 2026.
Each club is entitled to two votes:
The president and the immediate past president are the assigned delegates, but may designate another member(s) of the club to serve as a delegate in their absence.

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* Kiwanis Club of (name of club)

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* Club Number   K-

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* Division

Delegate 1

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* Name of Club President (or other desingated delegate)

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* Member K-Id Number:

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* Delegate 1 Email Address:

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* Mailing Address

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* City

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* State

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* Zip:

Delegate 2

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* Name of Immediate Past President (or other designated delegate):

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* Member K-Id Number:

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* Delegate 2 Email Address:

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* Mailing Address

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* City

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* State

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* Zip:

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* Club Secretary Name:

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* Club Secretary's Email:

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* Submitted by: (if submitted by someone other than club sectary)

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* Club office:

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