Alpha Esquire Application

What are your hobbies?*
What do you do in your spare time?*
What is something you aspire to do and why?*
What are your education and career goals?*
I attest that the information provided is true and accurate to the best of my knowledge: Applicant's Signature*

Clear

Medical Information
Does the Applicant have any medical conditions or take any medications?*

YesNo
If yes, please list of the applicant's medical conditions, medications being taken and dosages.*
Does the applicant have any allergies or is he allergic to anything? (If so please list the applicant's allergies or things he is allergic to).*
Physicians Name*

First NameLast Name
Physicians Phone Number*
Please enter a valid phone number.

I consent for the release of any media production related to voice, picture, and/or likeness and reproductions in any form, with or without alterations or commissions by Alpha Esquires of Wichita, KS / Sedgwick County or their designee, for the purpose of advertising, purpose of trade or for such purposes of a similar nature as it may be deemed necessary and advantageous. This release is irrevocable.
Choose ONE*

I hereby consentI hereby do not consent
Parent/Guardian Consent*

Clear
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PARENT(S)/GUARDIAN(S) INFORMATION