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Lt. Governor Report Form

If you do not receive a copy in your e-mail in one (1) day, please contact the Technology Chair.

Must be submitted by the 15th of each month.

Please indicate who you would like to send a copy
of this form to by entering their full email address.
(Separate multiple email addresses with commas).

Copies of this report will automatically be sent to:
• The Ltg Completing This Form
• Your Regional Advisor
• District Administrator
• District Governor
• Optional email addresses entered above.

LIEUTENANT GOVERNOR IDENTIFICATION
First Name:
Last Name:

Report Month:
Report Year:
Your Division:
Your Region:

TROUBLED CLUB INFORMATION
CLUB 1

Club Name

Have You Contacted?

The Club
The Kiwanis
The School
The Regional Advisor

Do you recognise
the problem?

Action Taken

What outside help
is needed?

TROUBLED CLUB INFORMATION CLUB 2
Club Name
Have You Contacted?	The Club The Kiwanis The School The Regional Advisor
Do you recognise the problem?
Action Taken
What outside help is needed?

NEW CLUB BUILDING INFORMATION
1. Club Name
Step

New Club Building Comments?

CONTACT AND COMMUNICATION
Have you held a divisional meeting this month?
If so, give a report on attendance and business conducted:

Have you met or contacted your regional advisor this month?
If so, in what form?

Have you communicated with the members of the District Committee on which you serve?
If so, in what form?

INDIVIDUAL CLUB EVALUATION AND CONTACT SUMMARY
1. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

2. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

3. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

4. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

5. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

6. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

7. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

8. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

9. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

10. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

11. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

12. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

13. Key Club Name
Club contact
Kiwanis contact
Iolian—Keynoter
Tasks and Participation	Report Interclub Participated in District Project
Outstanding club project
Rating

COMMENTS AND CONCERNS
Please enter any general comments or concerns

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