Kappa League Candidate Application

APPLICANT INFORMATION

Name:

(Last) (First) (Middle)

Age: Date of Birth:

High School: Grade:

Home Address:

(Street) (City) (State) (Zip)

Student Home Telephone Number:

Student Mobile Telephone Number:

Student Email Address:

Parent(s)/Guardian(s) Name:

Parent(s)/Guardian(s) Telephone Number:

(Area code) (Number)

Parent(s)/Guardian(s) Email Address:

Emergency Contact:

Emergency Contact (Phone):

APPLICANT’S ACKNOWLEDGMENT

I wish to participate in the Southaven Alumni and Southaven Leadership Foundation Kappa League program. I agree to comply with all program guidelines, and I understand that failure to comply with program guidelines may result in termination of my participation.

APPLICANT’S SIGNATURE: DATE:

EDUCATION BACKGROUND

Grade Point Average:

Weighted: Unweighted:

School Activities: (Past and Present):

School Awards and Honors: (Past and Present):

Community Involvement: (Past and Present):

HIGHEREDUCATIONASPIRATIONS

LISTCOLLEGES/UNIVERSITIESYOUAREINTERESTEDINATTENDING:

THIS SECTION OF THE APPLICATION SHOULD BE COMPLETED BY THE

PARENT AND/OR GUARDIAN OF THE YOUNG MAN APPLYING FOR THE KAPPA

ALPHA PSI BEAUTILLION MILITAIRE PROGRAM)

PHOTO RELEASE

I give permission to the Southaven Alumni Chapter of Kappa Alpha Psi Fraternity, Inc. and the Southaven Leadership Foundation to use or release any photos of my child, taken for the purpose of promoting the Fraternity and its Kappa League/Guide Right Program.

PARENT/GUARDIAN SIGNATURE: DATE:

PARENTAL ACKNOWLEDGEMENT

I hereby give my permission for my child to participate in the Southaven Alumni and Southaven Leadership Foundation, Kappa League Program. I understand that the Southaven Alumni Chapter of Kappa Alpha Psi Fraternity, Inc. and Southaven Leadership Foundation are not responsible for personal injury or loss of property. I understand that my child is free to leave the program at any time and must comply with the Kappa League guidelines. I agree to immediately update this application when any of the information changes.

PARENT/GUARDIAN SIGNATURE: DATE:

MEDICAL INFORMATION

Please list any medical conditions, health concerns, or allergies your child has that we should be aware of.

RELEASE FOR MEDICAL TREATMENT

In the event of an emergency and the inability of the Southaven Alumni Chapter or Southaven Leadership Foundation of Southaven officers and/or Advisors and/or Director of the Kappa League Program to obtain my consent, I hereby give permission for the Southaven Alumni Chapter of Kappa Alpha Psi Fraternity, Inc. and Southaven Leadership Foundation to authorize any medical treatment or surgery which a physician or surgeon shall deem necessary for my child.

PARENT/GUARDIAN SIGNATURE: DATE:

In the case of an emergency, which hospital or urgent care facility do you prefer to have your child transported to?

Hospital/Urgent Care Facility:

Primary Care Physician’s Name:

Why Kappa League? (Please explain in no more than four paragraphs.)