DISTINGUISHED CLUB AWARD APPLICATION FORM

(PLEASE TYPE)

Circle K Club of Click here to enter text.

PART ONE:CLUB INFORMATION

A. CIRCLE K CLUB ADMINISTRATION -

CLUB MEETINGS

1.How many club meetings were held:

a. During the school year that was attended by an advisorClick here to enter text.

b. During the school year that had a speaker or programClick here to enter text.
(includes Governor’s visits)

c. During the summer (or other break period)Click here to enter text.

d. Special meetings (banquet, induction, etc.) Click here to enter text.

e. Board meetingsClick here to enter text.

f. Average club-meeting attendance as a percentage of dues

paid membership(round to the nearest whole number):Click here to enter text.%

CLUB REPORTS

2.80% of all MRF reports completed and submitted on time:

  1. Monthly Report Form (submitted monthly to district):

i.President☐YES ☐NO

ii.Secretary☐YES ☐NO

iii.Treasurer☐YES ☐NO

  1. Club Election (submitted to district) ☐YES ☐NO

DUES PAYMENT

3.Date dues received by Circle K International:Click here to enter a date.

DIVISION INVOLVEMENT

4.Activities in which the club participated:

a. Divisional Council Meeting(s) ___ out of ___

b. Division-wide rally(ies) ___ out of ___

c. Division-wide service project(s) ___ out of ___

CLUB COMMUNICATIONS

5.Did the club utilize either of these forms of communications for members?

a.Club newsletter with a minimum of FOUR (4) issues☐YES☐NO (this does not include a monthly calendar)

b.Up-to-date club website☐YES☐NO

B. CLUB MEMBERSHIP

EDUCATION & DEVELOPMENT PROGRAMS

1.Did the club provide a special program for new member

induction, including a ceremony, and pin presentation? ☐YES ☐NO

2.Did the club provide a formal program for member

orientation and education including the new member

handbook, Circle K magazine, videos, etc? ☐YES ☐NO

CONVENTION ATTENDANCE

3.How many voting delegates attended the 2015 Indiana
District Convention?Click here to enter text.

4.How many voting delegates attended the 2015 Circle K
International Convention? Click here to enter text.

MEMBERSHIP ACTIVITIES

5.How many club social activities were held for all club members? Click here to enter text.

6.How many interclubs were held with other Circle K Clubs? Click here to enter text.

MEMBERSHIP GROWTH

7.What is the increase (decrease) of dues paid members over

the previous year? Click here to enter text.%

C. LEADERSHIP

OFFICER TRAINING

1.Did the club president, secretary, and treasurer attend the 2016 Indiana District Club Officer Training Conference (COTC)? ☐YES ☐NO

2.Other than the 2016 Indiana District COTC, did your club

participate in any formal officer training?☐YES ☐NO

LEADERSHIP DEVELOPMENT

3.Has your club conducted or participated in:

a.The 2016 Indiana District Membership Development ☐YES ☐NO

and Education Conference?

b.A club officer/member leadership retreat? ☐YES ☐NO

4.Has the club had during the past year:

a. A candidate for District or International office? ☐YES ☐NO

b. A District officer or committee member? ☐YES ☐NO

c. An International officer or committee member? ☐YES ☐NO

D. KIWANIS FAMILY INVOLVEMENT -

SPONSORING KIWANIS CLUB INTERACTION

1.Have sponsoring Kiwanis club members attended a minimum

of FIVE (5) Circle K meetings? ☐YES ☐NO

2.How many times have members of the club attended the
sponsoring Kiwanis Club’s meetings? Click here to enter text.

3.Has the club participated in joint service projects with the

sponsoring Kiwanis club? ☐YES ☐NO

4.Has the club jointly sponsored a Builders Club or K-Kids

with the sponsoring Kiwanis club? ☐YES ☐NO

5.Has the club participated in at least one service project with a

Kiwanis club (other than the sponsoring Kiwanis), Key Club,

Builders Club, K-Kids, Aktion Club,

or other Kiwanis Family organization? ☐YES ☐NO

KIWANIS FAMILY INTERACTION

6.Has the club presented a program at a Builders Club, K-Kids,

Key Club, Aktion Club or Kiwanis meeting? ☐YES ☐NO

7.Has the club participated in at least one interclub with a

Kiwanis club (other than the sponsoring Kiwanis), Key Club, Builders Club, K-Kids Aktion Club,

or other Kiwanis Family organization? ☐YES ☐NO

A.SERVICE PROJECTS

List all service projects and activities the club has completed during the administrative year. The projects should be organized by month. If more than fifty (50) projects have been undertaken, list the fifty (50) projects involving the greatest number of members and producing the greatest number of service hours first. For a recurring project (for example, daily raising and lowering of school flags), treat the project as a single project for each month.

Provide the month, brief project description, number of members participating, and number of service hours completed by Circle K members during the month. This will be completed in the google form. An example is provided.

Total the number of projects and enter the number in the scoring box below. Attach the list to this report. An excel sheet will not be allowed, we will not be responsible counting the service hours and service projects.

Project Description / Month / # Members / Service Hours
1. Reading Buddies / April 2005 / 12 / 48
2. School Trash Pick-up / April 2005 / 17 / 44
3. Bake Sale for IDD / April 2005 / 18 / 36
4. Pen Pals with elementary school / April 2005 / 15 / 60
5. Reading Buddies / May 2005 / 12 / 48
6. Ushers at Graduation Ceremonies / May 2005 / 16 / 31

B.SERVICE HOURS

Total the number of service hours for the fifty (50) best projects of the club which have

been listed (see section A above). Divide the service hour total by the number of dues

paid members in the club. Round to the nearest whole number. Enter the number in

the scoring box to the right.

C.SERVICE FUNDRAISING

Total the money raised by the club for non-profit, educational and other

charitable purposes. Enter the figure on the blank to the right. $______

Total money raised per member? (divide total money raised by number of members) $ ______