KAPPA LEAGUE
Chattanooga Guide Right/Kappa League Application
“Training for Leadership Since 1922”
Print
Name in Full__________________________________________________________ Age Grade ______
(Last) (First) (Middle)
Present
Address________________________________________________________________________ Telephone Number
(Street) (City) (State) (Zip)
Permanent
Address Telephone
Number
Date
of Birth_________________________Email Address______________________________________
Emergency Contact Information
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Name
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Relationship
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Place of Employment
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Occupation
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Home Phone
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Work Phone
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Application should be returned to:
Kappa League Director
P.O. Box 8753. Chattanooga,
TN.37404
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1
Educational Background
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Name of School
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Street Address
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City/State/Zip
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Principal/Teacher
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Phone
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GPA (based on 4.0 scale)
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HIGHER EDUCATION ASPIRATIONS
List Colleges/Universities/ Technical
Schools you are interested in
attending: __________________________________________________________________________
_________________________________________________________________________________________________________________________________________
COMMUNITY INVOLVEMENT
List
Honors and Outstanding Achievements you have received:
List
community organizations, which you have 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 Chattanooga Kappa League,
what are your expectations? _____________
Why
are you interested in participating in the Chattanooga Kappa League? ________ ____________
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3
FOR STATISTICAL PURPOSES
Number
of Persons Living in Household:_____________________
Youth
Lives With: ¨Mother ¨Father ¨Both ¨Grandparents ¨Other ______________________
Nationality:
¨Black ¨White ¨Hispanic ¨Asian ¨Other
Please
list any medical conditions or allergies your child has that we should be aware
of:___________________________________________________________
__________________________________________________________________________________________________________________________________
Does your child have a hearing problem? ¨Yes ¨No If so, does he wear
a hearing aid? ¨Yes ¨No
Does
your child have a vision problem? ¨Yes ¨No If so, does he wear glasses? ¨Yes ¨No
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4
Has
your child had a serious illness, injury or hospitalization in the past year? ¨Yes ¨No
If
so, please describe:
_____________________________________________________________________________________________________
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Has
your child ever been convicted of a misdemeanor or felony? ¨Yes ¨ No If so, complete the following: (Do not
include minor traffic violations)
DATE:
OFFENSE: PLACE :
DISPOSITION:
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PHOTO RELEASE
I give permission to the Chattanooga 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 ______________________________________ DATE____________
PARENT/GUARDIAN
SIGNATURE ______________________________________ DATE____________
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5
RELEASE FOR MEDICAL TREATMENT
In
the event of an emergency and the inability of the Chattanooga Chapter officers
to obtain my consent, I hereby give permission for the Chattanooga 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 ______________________________________ DATE____________
PARENT/GUARDIAN
SIGNATURE ______________________________________ 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 Chattanooga Guide
Right/ Kappa League program. I
understand that the Chattanooga 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 ______________________________________ DATE____________
PARENT/GUARDIAN
SIGNATURE ______________________________________ DATE____________
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MEMBER ACKNOWLEDGMENT
I wish to participate in the Chattanooga 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 Chattanooga
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 ______________________________________ DATE
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“I
HEREBY REQUEST THAT SPONSORS, REFERENCES, PREVIOUS AND CURRENT EMPLOYERS
CONTACTED BY THE CHATTANOOGA ALUMNI CHAPTER OF KAPPA ALPHA PSI FRATERNITY AND
CHATTANOOGA KAPPA LEAGUE IN CONNECTION WITH THIS APPLICATION, FULLY RESPOND
TO ALL INQUIRIES CONCERNING ME AND SPECIFICALLY WAIVE PRIOR WRITTEN NOTICE OF
DISCLOSURE OF INFORMATION PERTAINING TO MY CHARACTER, PERSONNEL RECORD
INFORMATION, INCLUDING DISCIPLINARY REPORTS, LETTERS OF REPRIMANDS OR OTHER
DISCIPLINARY ACTION. IN CONSIDERATION
OF THE ACCEPTANCE OF MY APPLICATION, I RELEASE THE CHATTANOOGA GUIDE RIGHT/KAPPA LEAGUE
AND SPONSORS, REFERENCES, PREVIOUS AND PRESENT EMPLOYERS OF ANY CLAIMED
LIABILITY ARISING OUT OF SUCH RESPONSE AND DISCLOSURE.”
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“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 ELITE CHAPTER OF THE KAPPA
LEAGUE, I AGREE TO COMPLY WITH ITS RULES AND REGULATIONS. I HEREBY AUTHORIZE MY SPONSORS, REFERENCES,
PREVIOUS, AND PRESENT EMPLOYERS TO GIVE ANY INFORMATION REGARDING ME.”
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APPLICANT
SIGNATURE: DATE:
PARENT/GUARDIAN SIGNATURE______________________________________________DATE:______________________________
WORK EXPERIENCE
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PERSONAL REFERENCES
(Teachers
and Administrators Only.
Minimum
of three required)
Name/area code & phone #:
Name/area code & phone #:
Name/area code & phone #:
Name/area code & phone #:
X
Student Signature and Date
Page 9
STUDENT APPRAISAL FORM
(To be completed by school official)
Please
type or print the following:
Your name, title/position & phone
#:
How long have you known the student? years/ months:
Students class rank: GPA on
4.0 scale:
Please
discuss the student in the following categories: attitude, responsibility & leadership skills:
X