2023 Kiwanis Amplify

Kiwanis Amplify Registration

This form is for Kiwanis members ONLY. If you are not a Kiwanis member or need to register a non-member for the program, please use the alternate "Non-Member" form that can also be found on the Kiwanis Amplify website.

How many people are you registering?*

Note this form allows a maximum of 12 registrations at a time, please submit a second form if registering more than 12

Member Registration 1

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 2

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 3

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 4

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 5

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 6

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 7

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 8

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 9

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 10

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 11

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Member Registration 12

Member Name*

First Name

Last Name

District Name*

Member Email*

Member Phone*

Club Name*

KI Member ID

Referral

If someone referred this person to the program, please enter their name here.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Information about registering party:

Name*

First Name

Last Name

District Name*

Email (registered with Kiwanis) *

Phone Number*

Club Name*

KI Member ID

Referral

If someone referred you to the program, please enter their name here.

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Payment Information

Registrations

Registration Fee $

Amount Due $

Credit Card*

If you have questions about registration please contact Lynsy Wikel at kiwanisamplify@kiwanis.org

All Kiwanis Amplify learning modules and contents are fully owned by Kiwanis International. By registering for the Kiwanis Amplify program, the registrant agrees that he/she may not copy, reproduce, distribute, publish, or modify any of the Kiwanis Amplify contents or modules without the express written consent of Kiwanis International.