Southfield Alumni Chapter Reclamation Form

Reclamation Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email (please use a personal email if possible)*
example@example.com
Birth Date*

MonthDayYear
Emergency Contact*

First NameLast Name
Emergency Contact Mobile Phone Number*
Please enter a valid phone number.
Emergency Contact Email
example@example.com
At what level did you pledge Kappa Alpha Psi?*
Chapter of Initiation (use greek letter designation as well as university name if it applies)?*
Date of Initiation?

MonthDayYear
Date
What is your membership number (type "unknown" if you do not know it at this time)?*
Do you have a desire to contribute to any of the following committees (you may choose more than one)?

Community Service CommitteeHealthy Kappa CommitteeHousing CommitteeKappa Kulinary CommitteeGuide Right/Kappa LeagueSouthfield Kappa FoundationVintage Kappa CommitteeMillenial CommitteePolitical & Social Action CommitteeReclamation CommitteeRAN (Recognition, Achievement, Networking) CommitteeSocial Events CommitteeStrategic Planning CommitteeTechnology CommitteeUndergraduate Advisor Committee
Note: Payment of dues on this site does not include annual Grand Chapter dues. The only way to pay Grand Chapter Dues is through the Brothers Only Login under the Members Only tab on www.kappaalphapsi1911.com.

Select Only One (payment includes dues and processing fees)*

Northern Province Life Member(Current life member but not financial at the alumni level)

$294.00 Quantity

Non-Northern Province Life Member(Non-life member but not financial at the alumni level)

$351.00 Quantity

Total

$0.00