Registration Form

Please complete this online form to register for International Convention.

This registration form and a $500.00 deposit are due by Friday, May 3, 2024.

Checks should be made payable to "New York Key Club Tour" and mailed to:

John Goldstein

590 Mullock Road

Port Jervis, NY 12771

ATTN: ICON 2024

*Deposits are non-refundable

Personal Information

First Name *

Last Name *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address (must NOT be a school email) *

Date of Birth: * +

Key Club Information

High School *

Division

Current Key Club Position *

Will you be one of your club's two delegates? *

Yes

No

Class Year

T-Shirt Size *

Have you attended ICON before? *

Yes

No

From which region will you depart? *

Albany

New York - LaGuardia

Emergency Contact

Please provide two (2) emergency contacts, at least one who resides in your permanent home.

Name: *

Relationship: *

Cell Phone Number: *

Name: *

Relationship: *

Cell Phone Number: *

Dietary Restrictions (select all that apply) *

Please list any other food allergies, dietary restrictions, or medical conditions that you
would like chaperones to be aware of.

Required Documents

Medical Form (PDF format only) *

Click here for the Medical Form

Code of Conduct (PDF format only) *

Click here for the Code of Conduct

Photo Release Form (PDF format only) *

Click here for the Photo Release

Registration Form and $500.00 Deposit Due: May 3, 2024

Checks should be made payable to "New York Key Club Tour" and mailed to:

John Goldstein

590 Mullock Road

Port Jervis, NY 12771

ATTN: ICON 2024