#CAP Application

#CAP Program Student Application Form
Parental Consent & Responsibility

	As the parent or legal guardian of {name} (hereinafter to as “she” or “her” or “he” or “his”), I hereby certify and affirm the following:
	1. I am legally entitled to give consent for her/his participation in the #CAP^SM program.
	2. I acknowledge that she/he will be enrolled in 11th or 12th grade in good academic standing.
	3. I am aware that upon application to the #CAP^SM program, I must provide a copy of her/his most recent grade report.
	4. I understand that her/his personal and private information will not be shared with any individuals, agencies or institutions without my written consent.
	5. I understand that she/he will be involved with workshops and activities that seek to prepare her/him for the #CAP^SM admissions process and #CAP^SM which may also include community service and cultural enrichment activities.
	6. I understand that it is my responsibility to make sure that she/he is present at all scheduled activities.
	7. I authorize permission for her/him to attend all #CAP^SM excursions that are off-site from the regular meeting place.
	8. I understand that guests (i.e., younger siblings, friends, un-enrolled students) should not be brought to the meeting or activities without prior consent or knowledge of the #CAP^SM program personnel.
	9. I understand that her/his admission and participation in the program is voluntary and may be terminated by any party of this agreement at any time.
	10. I authorize the #CAP^SM program personnel to transport her/him (or arrange transportation) to a hospital or medical facility in the event that I cannot be reached and authorize consent to examination, care and treatment as deemed necessary by a licensed physician or dentist.
	11. I understand that she/he may be photographed or videotaped during the program meetings and activities and give my consent for use of such images by Alpha Kappa Alpha Sorority, Inc. and the #CAP^SM program personnel in print or electronic media used to promote the program.
	12. I understand that as the parent or legal guardian, I may be called upon to attend a mandatory parental orientation, periodic meetings and program activities. In the event I cannot attend, I agree to send an adult representative in my place.
	13. I relieve Alpha Kappa Alpha Sorority, Inc. and #CAP^SM program personnel from any liability that may arise during her/his involvement in the #CAP^SM program meetings and activities.
	14. I understand that this form will be kept on file by Alpha Kappa Alpha Sorority, Inc. and the #CAP^SM program personnel.
	15. Termination of a student’s involvement in #CAP^SM will be in writing.
By affixing my signature below, I certify that I have read all of the above information and agree with the provisions and my role and responsibilities.

Parent/Legal Guardian Name*

First NameLast Name
Relationship to Applicant/Participant*
Contact Cell Number *

Area CodePhone Number
Email *
example@example.com
Parent/Legal Guardian Signature

Clear

#CAP Program Student Application Form
Student Code of Conduct & Responsibility Contract

As a participant of the #CAP^SM program:

1. I agree to abide by the rules and regulations set forth by the #CAPSM personnel and to conduct myself with respect.

2. I agree to be cooperative and follow instructions ensuring that I respect adults and all #CAP^SMpersonnel.

3. I will not bully or participate in negatively speaking to or of anyone nor act in a violent manner.

4. I will provide a copy of my recent grade report with the application and upon request of the #CAP^SM personnel.

5. I will remain in good academic standing.

6. I understand that I must notify the #CAP^SM program personnel of any absence from Program activities.

7. I understand that my personal and private information will not be shared with any individuals, agencies or institutions without my parent’s written consent.

8. I will participate in workshops and activities that seek to prepare me for the #CAP^SM admissions process.

9. I will be fully engaged in attending program meeting and activities that may include civic and cultural activities.

10. I understand that I cannot bring guests to meetings or activities without prior consent or knowledge of the #CAP^SM program personnel.

11. I understand my admission and participation in the program is voluntary and maybe terminated by any party of this agreement at any time.

12. I understand that I may be photographed or videotaped during the program meetings and activities for use of such images to be used by Alpha Kappa Alpha Sorority, Inc. and #CAP^SM program personnel in print or electronic media for promotion of the program.

13. I understand that this form will be kept on file by Alpha Kappa Alpha Sorority, Inc. and the #CAP^SM program personnel.

14. I will evaluate the #CAP^SM program when requested.

15. Termination of a student’s involvement in #CAP^SM will be in writing.

By affixing my signature below, I certify that I have read all of the above information and agree with code of conduct and responsibilities as a participant of the #CAP^SM program.

Student/Applicant Name*

First NameLast Name
Contact Cell Number *

Area CodePhone Number
Email *
example@example.com
Student/Applicant Signature

Clear

#CAP Program Student Application Form

Applicant Information

Parental/Legal Guardian Information

Emergency Contacts

#CAP Program Student Application Form

Parental Consent & Responsibility

#CAP Program Student Application Form

Student Code of Conduct & Responsibility Contract

#CAP Program Student Application Form

#CAP Pre-Assessment

Please provide the following information: