Alpha G.E.N.T.S Application Gaining Essential Networking Tools for Sucess Name* First NameLast Name Date of Birth* -Month -DayYearDate Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code High/Middle School: * School name Street Address Line 2 CityState / Province Postal / Zip Code Email* example@example.com Phone Number* Please enter a valid phone number. Academic Level* Junior HighFreshmanJuniorSeniorOther Current GPA* Back Next What school subjects do you like least and why? * Explain why you want to be in the Alpha G.E.N.T.S. Program: * How do you think you will benefit from the program? * Type a question* What are your career and education goals? * How would you rate your academic performance? * Please Select Excellent Good Poor Bad Have you received 1 or more grades of D or F?* YesNo If yes, how many?* In which subjects?* Back Next How would you rate your attendance performance?* ExcellentGoodPoorBad Absent* 1-3 days5 days6-10 daysover 10 days How would you rate your classroom behavior?* ExcellentGoodPoorBad How would you rate your attitude about school?* ExcellentGoodPoorBad Have you ever been suspended from school?* YesNo If necessary, would you be able to attend summer school?* YesNo Back Next In what other activities are you involved?* Are you willing to do community service projects as part of your coursework after school?* YesNo What is your post-secondary plan?* Community CollegeTech. Program4-Year UniversityWorkforceMilitary If there is one thing you would like to learn or do prior to graduating from high school what would that be?* Back Next Resume* Browse FilesDrag and drop files here Choose a file Cancelof Polo Size* SmallMediumLargeXLXXL Preferred Communication Method* EmailPhone I First Name* Last Name* attest to the fact I am a young male between the grades of 8-12 and actively enrolled in a middle school or high school program and wish to participate in the Alpha G.E.N.T.S. Mentorship Program. In addition, I (parent) give my son permission to participate in the Alpha G.E.N.T.S. Mentorship Program. I understand that even when every reasonable precaution is taken, accidents can sometimes still happen. Therefore, in exchange for Delta Rho Lambda Chapter of the Alpha Phi Alpha Fraternity, Inc. allowing me (and my son) to participate in Alpha G.E.N.T.S. Mentorship Program, I understand and expressly acknowledge that I release the Delta Rho Lambda Chapter and its members from all liability for any injury, loss or damage connected in any way whatsoever to my son’s participation in the Alpha G.E.N.T.S. Mentorship Program, whether on or off the premises occupied at the given time. I understand that this release includes any claims based on negligence, action, or inaction of the fraternity, its members, officers, directors, and guests. I have read and am voluntarily signing this authorization and release. I have read this form and other program documentation and grant permission for my son, listed above, to participate in all activities provided by the Alpha G.E.N.T.S. Mentorship Program. I further give permission for my son’s photograph to be taken for use by the chapter in all fraternal publications and for release to local media outlets.Signature* Student SignatureSignature* Parent Signature Phone Number* Please enter a valid phone number. Date Signed* /Month /DayYearDate Back Next PERMISSION TO ADMINISTER/DISPENSE MEDICATION As a Parent/Guardian of First Name Last Name I give permission for the mentors and adult supervisors of the Alpha G.E.N.T.S. to administer medication to my child. This means they can help my son take his medication by providing water, handing to him an individual dose, or measuring a dose of liquid medication. The adult staff will not place a pill or liquid into my child’s mouth or force him to swallow medication. I agree to send medication with my son in original labeled packets or bottles, indicating the dosage, times of administration, and dietary precautions. A physician’s order must be provided prior to any member of the fraternity administering any medication. All medication must be held in the original, labeled containers, and kept on the person of the child, or if requested with an authorized adult staff for safekeeping. If so indicated, my child may self-medicate (i.e., asthma inhaler, OTC medicines for cold/flu, diabetics) with prior/appropriate notice in writing to the school office from the parent with a physician’s order (if applicable). My permission is valid for the duration of my child’s/ward’s enrollment in the Alpha G.E.N.T.S. Mentorship Program. I may revoke permission as expressed in this release, in writing, at any time. This document must be signed by all parents/guardians whose child requires medication at any time during their involvement with the program. Signature* Parental SignatureParent Name* Print First and Last Name Phone Number* Please enter a valid phone number. Date Signed* /Month /DayYearDate Back Next Initials* My child (or I) may self-medicate. See the attached documentation. (Parent Initial) Date Signed* /Month /DayYearDate Initials* My child (or I) does not require such services at this time. (Parent Initial) Date Signed* /Month /DayYearDate Initials* Parent/Guardian initial authorizing medication choice above. (Parent Initial) Date Signed* /Month /DayYearDate Back Next PERMISSION FOR COMMUNITY OUTINGS/FIELD TRIPS As Parent/Guardian of First Name Last Name I understand that involving my son in the community is an integral part of programming for the Alpha G.E.N.T.S. Mentorship Program. I grant permission to the staff to take my son into the community for educational, vocational, and social/recreational activities. This may include the use of various transportation modes including but not limited to public transportation, chartered bus, or agency vehicle. I understand notices will be sent to me regarding each scheduled activity. If there is a specific event, I do not want my son to participate I may call or write to revoke my permission. My permission as expressed in this release is valid for the duration of my child’s/ward’s enrollment in the Alpha G.E.N.T.S. Mentorship Program. Signature Parental SignaturePrinted Parent Name*Parent/Guardian Initial authorizing field trips Back Next PERMISSION TO USE PHOTOGRAPHY/VIDEO RECORDING As Parent/Guardian of First Name Last Name I will allow my child/ward to be photographed and or video-recorded for the purpose of educational experiences, academic skill acquisition, print publications, media relations, vocational training or for inclusion in his student file. Photographs and video recordings may be posted on program bulletin boards, social media websites, and fraternal publications, and for release to local media outlets. Should I refuse to grant permission as stated in this release, I understand that my child/ward will not be excluded from all activities in which photographs and video films are being taken. Signature blank*Initials of Parent/Guardian authorizing photography/ video recording Confirmation Signature: I acknowledge receipt of this page and agree to the items where I have placed my initials and/or signature Name* First NameLast Name Parent Signature* Name* First NameLast Name Student Signature* Date* -Month -DayYearDate SubmitSubmit Should be Empty:
