2021 Representative Assembly Delegate Report Form

Delegate Report Form

2021 Representative Assembly
Questions and comments should be directed to:
Sarah Meyer at sarah.meyer@knea.org or 785-232-8271

Please complete the following information. (Refer to the memo mailed to you in September for your local association membership and allocated delegates and alternates. This is based on your January 15, 2020 local association membership.)
Local President Name *
Local Association (please type full name, no initials) *
E-mail *
Local Membership Count *
Number of Allocated Delegates and Alternates *
UniServ District *
List delegates below and provide ethnic/minority information for each by using the following codes:

1. American Indian/Alaska Native
3. Black
4. Hispanic
5. Caucasian (not Hispanic origin)
6. Asian
7. Native Hawaiian/Pacific Islander
8. Other Racial or Ethnic Minority, please specify: ______________________

Delegates:
Delegate 1:
Delegate 2:
Delegate 3:
Delegate 4:
Delegate 5:
Delegate 6:
Delegate 7:
Delegate 8:
Delegate 9:
Delegate 10:
Please list additional delegates - remember to include ethnicity. Thank you.
Alternates:
Alternate 1:
Alternate 2:
Alternate 3:
Alternate 4:
Alternate 5:
Alternate 6:
Alternate 7:
Alternate 8:
Alternate 9:
Alternate 10:
Please list additional alternates - remember to include ethnicity. Thank you.
Form completed by:
Name *
Email Address *
Position Held *
Should be Empty: