Kansas State Council Memorial Service Report Form

To submit a Memorial Service Report form, fill out and submit the following form. This form posts the responses to a mailto e-mail address, so not everyone will be able to use this form. If you cannot use this form, use the pdf file form provided by printing it and sending it to the State Chaplain.

Departed member:		Chapter Name & Number:
Jonquil girl/Chaplain:		E-Mail:

ESA Chapter(s) joined:

Date Joined ESA: Death Date:

Cause of Death:

Date of birth:

Will the President of the Chapter or appointed member be able to assist in honoring the departed at the Sunday Services at State Convention?

Response:

YES NO

If so, Please give name:


Surviving Family:

Chapter offices held:
(Check all that apply)

President VPresident Secretary(s) Treasurer Education Dir/Parliamentarian
Active Committee work

Briefly summerize the chapter activities and offices held locally.


Summary:

District offices held:
Check all that apply

District Chairman Co-Chairman Secretary(s) Treasurer Education Dir/Parliamentarian
Active Committee work

Briefly tell about any District or State involvement:


District/State Involvement:

Briefly give other information about her and other activities:


Other information:

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