Columbus (OH) Alumni Chapter Guide Right Application

Columbus (OH) Alumni Chapter Guide Right Application

1461 Mt. Vernon Avenue, Columbus, OH 43203 P.O. Box 151232 Columbus, OH 43215

Directions: This application should be filled out completely. Please print legibly. Applications are accepted every fall from October 1st to November 16th for the academic year.

Eligibility requirements: Students must be between the ages of 12 – 14 and must have the signed approval of their parents/guardian and must secure one recommendation from his school. Students may be interviewed either in person or via phone and submitting an application does not guarantee admission into the Guide Right program. The Guide Right program will be limited to 25 students per year.

Name: ______Date of Birth: ______

Address: ______

City State Zip

Current School: ______Grade: ______

Address: ______

City State Zip

Home phone number: ______Parent’s cell: ______

Mother’s Name: ______Live with?______

Father’s Name: ______Live with?______

Guardian’s Name: ______Relationship: ______(Under relationship list 1 for aunt/uncle, 2 for grandparent, 3 for sibling, 4 for other relative, 5 for foster services.)

List sports or other activities you are involved in:

______

List your goals:

______

List your interests:

______

Columbus Alumni Chapter of Kappa Alpha Psi Fraternity, Inc.

Gregory Dukes, Sr., Polemarch 1461 Mt. Vernon Avenue Columbus, OH 43203

Guide Right ProgramParent/Student Enrollment Form

I ______have read the parent’s code of conduct and agree to work with the

Insert (print) parent’s name

Guide Right representative to make sure my son will be successful in this program. I agree to make sure that my child attends the sessions scheduled on the Guide Right calendar if my son is accepted into this program. I will have my child dropped off at the appropriate time and will pick him up as scheduled at the conclusion of the program. If I cannot pick my child up or drop him off, I give my child permission to walk or catch public transportation to the school/facility or back home. I also give permission to have my son transported by car (if the box is checked on this form below). I recognize that some program meetings/activities will be held at the at the historic Kappa House (corner of Burt and Mt. Vernon Avenues).

I also agree that my son should honor general school rules and policies while both on campus or while off site at the Kappa House or at Guide Right sponsored programs and trips. If he does not honor or abide by the rules and regulations of the school and host agency he may be limited for growth opportunities in the program. I also agree and give permission to my son’s assigned Guide Right representative to secure school records if the representative is tutoring him as well.

The Columbus Alumni Chapter of Kappa Alpha Psi and the Guide Right Program will be released from any liability that may accrue based upon unintended/unfortunate circumstances, acts of God, or negligent behavior on the part of any participant.

___ Yes, I would like ______to participate in the program. Please print Son’s name/grade

Parent’s Signature______Date: ______

Top of Form

E-Mail address: ______GR representative transport? Yes No

Please mail application and enrollment form to: PO Box 151232 Columbus, OH 43215