Knights of Columbus

Fraternal Programs Report Form

Reporting Officer Name  
Membership Number  
Council Number  
State / Province  




If Other, Program Name:


Date(s) of Program :


Non Members
Total Volunteers
Total Volunteers
Hours (Per Person)
Total Volunteer Hours


Participants (Non-Volunteer):
Was your Pastor present?


Program Planning:
Time (Hours)
Members Recruited:
Local Currency


Icon Number (see icon bag):
Total number of prayer services:


Total coats distributed:


Number of Wheelchairs Funded:
Amount Donated to the Global Wheelchair Mission:
Containers Purchased:


Did your council conduct a Fundraiser/Wheelchair Sunday?
Did your council participate in distribution?


Total amount donated to Habitat for Humanity this year:


Name of Event:
Location of event attended:
  (City & State)


Type of Event:
Location Type:
Number of buses chartered/sponsored:


The deadline for submissions is the 15th day of the following month. Example: November nominations need to be received no later than December 15th.


Name of Nominee - Husband:
Number of Kids (if applicable):


Name of Nominee - Wife:
Number of Grandkids (if applicable):


Knights of Columbus Member?
Membership Number (If applicable):


Primary Email Address of Grand Knight:
Month of Nomination:


Primary Mailing Address of Nominee Family:
Address Line 1
Address Line 2
State / Province
Zip Code


Please explain the reasons your council selected this family. (Refer to #1993 - Family of the Month/Year - Guidebook for official selection guidelines.)
 250/250 Characters Limit


Is this a State Council Submission? (If yes, numbers on form should represent State Council events ONLY, not a cumulation of jurisdiction activity)


Total Number of Special Olympics Events Supported:


Distance Traveled to Transfer Rose (MI/KM):


Your Grand Knight must complete Form # 2863 for council refund.


Your Grand Knight must complete Form # 10057 for council refund.


Forms #10715 and #10716 must be completed for this program.


On a scale of 1-5 (with 5 being the highest) how engaged was your parish and council by this program?


What information or feedback would you like to share about your program? (To share more success stories, visit
 300/300 Characters Limit