Mobile Omega Lamplighters Application

Omega Lamplighters Application Packet
Omega Lamplighter Application Prospective Member Information Profile Please complete all information requested. Print (black ink) or Type.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
Phone Number*
Birthday*
Current Age*
Current School*
Current Grade*
Grade Point Average (un-weighted):*
Were you Referred By anyone(Member of Omega Psi Phi or Existing Lamplighter Family)*
Name of Parent/Guardian*
Cell number*
Email Address*
example@example.com
Organizations/Teams that you have participated in:*
Parent Release Form
"I hereby grant permission for my child participate in the Mobile Chapter of Omega Lamplighters. The Omega Lamplighters are supervised by members of the Rho Alpha Chapter of Omega Psi Phi Fraternity Inc. By signing this permission/waiver notice, you are releasing the Rho Alpha Chapter and Omega Psi Phi Fraternity, Inc. from all liability of accidents or injury that may result from meetings, outings, field trips or other activities which necessitate gathering or traveling. "In granting this permission, I also authorize members of Omega Psi Phi fraternity to transport my child to events by private or chartered vehicles. I specifically release and will hold harmless Rho Alpha Chapter of Omega Psi Phi Fraternity, Inc. their officers, & members of all liability which may arise as a result of such transportation.
Name*

First NameLast Name
Signature of Participant*

Clear
Date*

MonthDayYear
Date
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date
Health Information Form
Participant's Name*
Birth Date*

MonthDayYear
Date
Name of emergency contact*
Relationship*
Does this participant have any physical or emotional conditions of which that we should be aware?
Restrictions on activities*
Known Allergies*
I do hereby authorize necessary emergency measures in the treatment of my son if needed. I attest that my son is in good physical health and does not have any restrictions except what's noted on this form. I release Rho Alpha Chapter, Omega Psi Phi Fraternity, and its members from liabiltiy of any medical event during an activity. In the event of a medical emergency, I authorize immediate medical attention, to include hospitalization and proper treatment on behalf of my child.
Son Name*

First NameLast Name
Parent or Guardian Name*

First NameLast Name
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date
Code of Conduct Form 1D:
1. Possession and use of any drug, marijuana, tobacco, or alcohol is strictly forbidden. Violations will result in immediate dismissal from the activity and potential expulsion from the program.

2. Attendance of all Activities is expected. Three absences from activities/meetings may impact the status of involvement in the program.

3. We antcipate that all particpants may attend all activities/events until the offical conclusion. Early departures must have consent from the parent and acknowledgement of the advisor on site prior to exiting.

4. Any rules and guidance provided by the advisor/leadership of activities must be followed.

5. All local, state, and federal laws shall be followed.

6. No foul language or disruptive behavior will be tolerated.

7. Participants are expected to show respect and courtesy to advisors, chaperones, and fellow Lamplighter participants. The participant's parents will be notified immediately if any of the rules are broken. Any violators will not be allowed to participate in future activities, and risks dismissal from the Omega Lamplighters Program. All funds to partcipate in the program are nonrefundable. I AM committed to reaching my FULL potential!!!
Signature of Participant*

Clear
Date*

MonthDayYear
Date
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date
Letter of Intent/Letters of Recommendations

(Essay from potential Member) Please answer the following questions in your letter of intent (letters must not exceed 250 words):

What are your life goals (Career, Academic, and Personal)?

What weaknesses do you have that you believe this program can help you with?

What strengths will you bring to the Lamplighter program?

What do you hope to get out of this experience?

We are requesting 2 Recommendation letters to include:

A description of gifts, talents, motivations, and interests of the potential particpant. Mention how this program could benefit the candidate Recommendations may come from either a school faculty member, Coach, Pastor, or Member of Omega Psi Phi Fraternity.

*An official report card from the school attached to the letter of Intent is preferred.
Essay*

Cancelof
Report Card File Upload

Cancelof
Letter of Recommendation 1*

Cancelof
Letter of Recommendation 2*

Cancelof
Should be Empty:

Parent Release Form

Health Information Form

Code of Conduct Form 1D:

Letter of Intent/Letters of Recommendations

We are requesting 2 Recommendation letters to include:

*An official report card from the school attached to the letter of Intent is preferred.