Escort Parent/Guardian Consent Form

Dear Parent/Guardian:

Alpha Kappa Alpha Sorority, Incorporated® founded on January 15, 1908, at Howard University is the first Greek-letter organization established by African American college women. Alpha Kappa Alpha has more than 355,000 initiated members in graduate and undergraduate chapters located throughout the United States, Bahamas, Bermuda, Canada, Germany, Japan, Liberia, South Korea, South Africa, United Kingdom, the US Virgin Islands and Dubai.

Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega Chapter is currently accepting applications for its 19th Biennial Debutante Cotillion Program. The Debutante Cotillion Program is an excellent opportunity for young ladies to experience a wide array of cultural, academic, and social activities, while obtaining scholarship funds to support their future educational endeavors.

For over three decades, with support from the community, Theta Pi Omega Chapter has awarded thousands of dollars to deserving young adults in scholarship and book awards. We are proud of the Cotillion's legacy in positively impacting the lives of our young adults throughout our community and beyond.

The Debutante Cotillion Program is seeking young gentlemen who are high school juniors and seniors, who demonstrate exemplary academic achievement, possess exceptional character, and have outstanding involvement in extracurricular activities and community service to participate as Escorts.

Please carefully read, complete, and submit the consent form electronically no later than 11:59 pm, May 24, 2025.  If you have any questions, please contact the Debutante Cotillion Program Co-Chairmen via email at cotillion@thetapiomegachapter.org.

 

Tanya Y. Jackson, President

Penny McPherson Myers and Rita Toliver-Roberts, Cotillion Co-Chairmen

By signing the form below, I affirm that all contents of the 19th Biennial Debutante Cotillion Program application are accurate and complete, as submitted, to the best of my knowledge. I understand that falsified statements and misrepresentations will result in immediate dismissal from the program and that any fees paid up to that point are non-refundable. I authorize representatives of the 19th Debutante Cotillion Program committee to verify statements made in the attached application packet.

I agree that, as a parent/guardian of a Escort, I will:

• Pay a $150 non-refundable program fee by the established deadline of June 14, 2025; (Program fees not paid by the due date will result in dismissal from the program)
• Help my Escort sell no less than 1 Ad Journal page;
• Help my Escort sell no less than 2 Cotillion Ball tickets  to friends, family, and other supporters; and
• Help my Escort, participate to the fullest in all events and programs relating to the Debutante Cotillion Program.

Your signature below indicates that you have read and agree to the entire Application Contract. 

Media Release Form

I hereby grant Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter permission to use my or my child's likeness in a photograph/video in all its publications, including website entries, without payment or any other consideration.

I understand and agree that these materials will become the property of Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter and will not be returned.

I hereby irrevocably authorize Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter to edit, alter, copy, exhibit, publish or distribute this photo/video for purposes of publicizing Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my or my child's likeness appears.

I hereby hold harmless and release and forever discharge Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

I hereby certify that I am the parent or guardian of the above-mentioned child and do hereby give my consent without reservation to the foregoing on behalf of myself and this person.

It is the expectation of Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter that participants in the 19th Debutante Cotillion Program adhere to the tenets of high ethical standards and moral behavior. All participants shall refrain from inappropriate use of the social networks, including, i.e., Facebook, Instagram, TikTok, Vine, Snapchat, YouTube, Tumbler, etc. which negatively impact themselves, Alpha Kappa Alpha Sorority, Inc., or anyone else.

Alpha Kappa Alpha Sorority, Incorporated®, Theta Pi Omega chapter retains the right to exercise exclusive control, regarding the participation of any applicant in the Debutante Cotillion Program by declining an applicant’s participation; withdrawing the privilege of participation; and by further declining any participant’s participation in the Debutante Cotillion.

Each Parent/Guardian is requested to certify and affirm the truthfulness of each of the following statements by signing below: 

• My Escort is neither married, been married, nor will become married prior to or during the 19th Biennial Debutante Cotillion Program.
• My Escort is not parent,  nor will become a parent prior to or during the 19th Biennial Debutante Cotillion Program.
• My Escort has not been arrested, charged, nor convicted of a criminal violation, or has ever been the subject of any prior criminal violation, or any other violation of a rule or policy that reflects poor moral character.
• My Escort will not use illegal drugs or alcohol while participating in the 19th Biennial Debutante Cotillion Program.
• My Escort is neither the subject of a pending suspension or expulsion, nor been suspended or expelled from any school for any reason.

In the event of a change of circumstance after the date of this certification regarding any matter contained herein, I will immediately and forthrightly notify the Cotillion Chairmen of the details of any such matter, with the full understanding that the Theta Pi Omega Chapter retains the exclusive rights, at any time, to decline my participation for failure to adhere to all participation criteria.