Decatur Alumni Chapter - Kappa League Membership Application

Decatur (GA) Alumni Guide Right/Kappa League Application

"Training for Leadership Since 1911"
Applicant Information
New Applicant*

YesCurrent Member
If you're a current Kappa Leaguer, how many years have you been a member (Ex. 3 years)?
Applicant Last Name
Applicant First Name
Applicant Middle Name
Applicant Date of Birth

MonthDayYear
Date
Applicant Age
Applicant Home Address
(Applicant) Telephone Number
Applicant Permanent Address
Parent 1 Name
(Parent 1) Telephone Number
Parent 2 Name
(Parent 2) Telephone Number
Applicant Email Address
example@example.com
Applicant Current School Name
Applicant Current Grade Level
EMERGENCY CONTACT INFORMATION
Emergency Contact # 1 (Name)
Emergency Contact #1 (Relation to Applicant)
Emergency Contact #1 (Occupation)
Emergency Contact #1 (Contact Number)
Emergency Contact #1 (Email Address)
example@example.com
Emergency Contact # 2 (Name)
Emergency Contact #2 (Relation to Applicant)
Emergency Contact #2 (Occupation)
Emergency Contact #2 (Contact Number)
Emergency Contact #2 (Email Address)
example@example.com
HIGHER EDUCATION ASPIRATIONS
List any Colleges/Universities/Technical Schools you're wanting to attend.
What are your career aspirations?
COMMUNITY INVOLVEMENT
List Honors and Outstanding Achievements you have received
List community organizations, in which you've been involved
List any other school activities (varsity athletics, student government, volunteer work. etc.) you have been involved in
List any hobbies or interests
If you are granted the opportunity to participate in the Decatur Alumni Kappa League, what are your expectations?
Why are you interested in participating in the Decatur Alumni Kappa League?
FOR STATISTICAL PURPOSES
Number of Persons Living in Household
Applicant lives with

FatherMotherBoth ParentsOther
Applicant Nationality

BlackWhiteAsianHispanicOther
Please list any medical conditions or allergies your child has that we should be aware of
Does your child have a hearing problem?

YesNoIf Yes, does he wear a hearing aid?Other
Does your child have a vision problem?

YesNoIf Yes, does he wear glasses?Other
Has your child had a serious illness, injury or hospitalization in the past year?

YesNo
If Yes, please describe.
Has your child ever been convicted of a misdemeanor or felony? (Yes If so, complete the following: (Do not include minor traffic violations) - including said information will not exclude you from joining.

YesNo
If yes, Date of conviction

MonthDayYear
Date
If Yes, please describe.
PHOTO RRELEASE
I give permission to the Decatur Alumni Chapter of Kappa Alpha Psi to use or release any photos of my child, taken for the purpose of promoting the Fraternity and its Guide Right Program (Parent/Guardian Signature)

Clear
DATE

MonthDayYear
Date
RELEASE FOR MEDICAL TREATMENT
In the event of an emergency and the inability of the Decatur Alumni Chapter officers to obtain my consent, I hereby give permission for the Decatur Alumni Chapter of Kappa Alpha Psi to authorize any medical treatment or surgery which a physician or surgeon shall deem necessary for my child.
PARENT/GUARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
In case of an emergency, which hospital or urgent care do you prefer to have your child transported?
Hospital/Urgent Care Facility
Primary Care Physician's Name
PARENTAL ACKNOWLEDGEMENT
I hereby give my permission for my child to participate in the Decatur Alumni Guide Right/ Kappa League program. I understand that the Decatur Alumni Chapter of Kappa Alpha Psi is not responsible for personal injury or loss of property. I understand that children are free to leave the program at any time. I agree to immediately update this application when any of the information changes.
PARENT/GUARDIAN SIGNATURE

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DATE

MonthDayYear
Date
MEMBER ACKNOWLEDGMENT
I wish to participate in the Decatur Alumni Guide Right/Kappa League program. I promise to be careful to prevent damage to any other buildings that may be used while participating in activities with the Kappa League program. I also agree to obey the rules of the Decatur Alumni Guide Right/ Kappa League program, and that at any time I can/will be expelled from the Guide Right/ Kappa League program for conduct that is detrimental to the program.
MEMBER SIGNATURE

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DATE

MonthDayYear
Date
"I HEREBY REPRESENT THAT EACH ANSWER TO A QUESTION HEREIN AND ALL OTHER INFORMATION OTHERWISE FURNISHED IS TRUE AND CORRECT. I FURTHER REPRESENT THAT SUCH ANSWERS AND INFORMATION CONSTITUTE A FULL AND COMPLETE DISCLOSURE OF MY KNOWLEGDE WITH RESPECT TO THE QUESTION OR SUBJECT TO WHICH THE ANSWER OR INFORMATION RELATES. I UNDERSTAND THAT ANY INCORRECT. INCOMPLETE, OR FALSE STATEMENT OR INFORMATION FURNISHED BY ME MAY RESULT IN AUTOMATIC REJECTION. IN THE EVENT THAT I AM APPROVED FOR PARTICIPATION IN THE DECATUR ALUMNI CHAPTER OF THE KAPPA LEAGUE, I AGREE TO COMPLY WITH ITS RULES AND REGULATIONS. IHEREBY AUTHORIZE MY SPONSORS. REFERENCES. PREVIOUS, AND PRESENT EMPLOYERS TO GIVE ANY INFORMATION REGARDING ME."
APPLICANT SIGNATURE

Clear
DATE

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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DATE

MonthDayYear
Date
Should be Empty:

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Applicant Information

EMERGENCY CONTACT INFORMATION

HIGHER EDUCATION ASPIRATIONS

COMMUNITY INVOLVEMENT

FOR STATISTICAL PURPOSES

PHOTO RRELEASE

RELEASE FOR MEDICAL TREATMENT

PARENTAL ACKNOWLEDGEMENT

MEMBER ACKNOWLEDGMENT