subject_line
STATE CONVENTION REGISTRATION FORM
Registration and Event Ticket for 124th State Convention - May 19-21, 2023
*** ONE REGISTRATION FOR INDIVIDUAL OR FAMILY PER FORM ONLY ***
THERE WILL BE NO ON-SITE REGISTRATION. PRE-REGISTRATION ONLY.
Are You A Delegate, Non-Delegate/Alternate, or Guest?
*
Delegate
Non-Delegate/Alternate
Guest
Council Number
*
Membership Number
Current Role/Office
*
4th Degree: District Master
4th Degree: Vice Supreme Master
Council: Grand Knight
Council: Officer, Program Director, or Member
Council: Past Grand Knight
Diocesan: DD Coordinator
Diocesan: Membership Chairman
District Deputy
Former State Chaplain
Insurance: Field Agent
Insurance: General Agent
Kirwin Award Winner
Past State Deputy
State: Chaplain
State: General Program Director
State: District Deputy Director
State: Executive Assistant
State: FIA Program Directors
State: Legal Counsel
State: Membership Director
State: Officer
State: Special Warden
State: Staff
Supreme Representative/Invited Guest
Convention Committee Team Member
Prefix
Father
Deacon
Monsignor
Reverend
First Name
*
Last Name
*
Suffix
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
GUEST INFORMATION
Please Enter Guest Information Below If Attending
First Name
Last Name
Relation
Enter Men or Ladies Sunday Luncheon
1
First Name
Last Name
Relation
Enter Men or Ladies Sunday Luncheon
2
First Name
Last Name
Relation
Enter Men or Ladies Sunday Luncheon
3
First Name
Last Name
Relation
Enter Men or Ladies Sunday Luncheon
4
First Name
Last Name
Relation
Enter Men or Ladies Sunday Luncheon
CONVENTION REGISTRATION
A. Select Bundle Below
Convention Bundle: Convention Book, Name Tag, Ohio State Pin, Souvenir, Awards Presentation & Friday Night Party, State Deputy Banquet & Sunday Men's Luncheon (N/C)
B. Select Bundle Below (includes PayPal Fees)
Convention Bundle: Convention Book, Name Tag, Ohio State Pin, Souvenir, Awards Presentation & Friday Night Party, State Deputy Banquet & Sunday Men's Luncheon ($105)
A. # of Guest Bundles
Guest Convention Bundle: Convention Book, Name Tag, Ohio State Pin, Souvenir, Awards Presentation & Friday Night Party, State Deputy Banquet & Sunday Luncheon (N/C)
B. # of Guest Bundles (includes PayPal Fees)
Guest Convention Bundle: Convention Book, Name Tag, Ohio State Pin, Souvenir, Awards Presentation & Friday Night Party, State Deputy Banquet & Sunday Luncheon ($105)
List Any Dietary Restrictions
GOLF TOURNAMENT
Enter # Golfers Paying For (Includes PayPal Fees)
Friday: Monsignor Krispinski Golf Tournament ($73)
Includes: Coffee & Donuts, 18-Holes, Half Cart, and Box Lunch at the Turn
Are you solo or playing with others?
Solo. Please pair me with someone.
I would like to play with those listed below.
Golf Players Info
First Name
Last Name
Phone
Email
2
First Name
Last Name
Phone
Email
3
First Name
Last Name
Phone
Email
4
First Name
Last Name
Phone
Email
EUCHRE TOURNAMENT
Enter Number Playing Euchre
Friday: KofC Insurance Agencies Euchre Tournament ($0)
Do You Have A Partner?
Yes
No
Euchre Partner Info
First Name
Last Name
Phone
Email
2
First Name
Last Name
Phone
Email
STATE COUNCIL ROOM INFORMATION
Please indicate your arrival and departure dates from the State Convention below.
Arrival Date
+
Departure Date
+