InterPACK Individual Registration

Individual Registration Type(Required)

Circle K Student

Kiwanis CK Committee

Kiwanian / Guest

School Name

Kiwanis Club of

Name(Required)

First Last Preferred Name

Pronouns

Position(Required)

Cell Phone(Required)

Email(Required)

Dietary Restrictions

Do you have any dietary restrictions?(Required)

If yes, please provide details:

Total

Payment(Required)

If paying with a check, please make the check payable to PA Circle K and mail it to: PA District Kiwanis International, P.O. Box 62, Dillsburg, PA 17019. Registration will be cancelled and you will be billed for 50% of the cost, if your check is not received by October 9, 2026 at 5:00 PM.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Kids Need Kiwanis

InterPACK Individual Registration

Dietary Restrictions

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