• Please report clubs granted fall semester club satellite status by December 15th and spring semester club satellite status by May 15.
  • This form may only be completed by a club president or secretary.
  • The submission of this form serves as an agreement between the active CKI club and its satellite club.
  • This form reports the members of the satellite club. Do not report satellite members through the Membership Update Center.
  • For complete information regarding club satellites of Circle K International, please refer to Article 6, Section 5, of the International Bylaws.
  • E-mail completed form to CKI Director Chris Martz at or mail to Kiwanis International, 3636 Woodview Trace, Indianapolis, IN 46268.

Satellite and Host Club Information

District:
Click here to enter text. / Host Circle K Club:
Click here to enter text.
Satellite Circle K Club:
Click here to enter text. / Key Number of Host Circle K Club:
Click here to enter text.
Satellite Club City:
Click here to enter text.
Satellite Club School Enrollment:
Click here to enter text.

Satellite Approvals

Top of Form

The form completed by (full name):
Click here to enter text. / Email Address:
Click here to enter text.
The person completing this form is (Click each box that applies):
Club President Club Secretary
The above satellite club has been approved by (Click each box that applies):
The host/active Circle K Club
The host/active club’s sponsoring Kiwanis Club.
Kiwanis Club of:Click here to enter text.
The CKI District Board of Officers
The Circle K International Director
(If not preapproved prior to completing this form; the director can approve upon the submission of this form)

Bottom of Form

Satellite Members

Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.
Name: Click here to enter text. / Postal Code:Click here to enter text.
Mailing Address: Click here to enter text. / Email Address:Click here to enter text.
City:Click here to enter text. / Birth Date (MM/DD/YY):
Click here to enter text.
State/Province: Click here to enter text. / Gender: Click here to enter text.