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I hereby consent _ I hereby do not consent _ and/or theirĭesignee, for the purpose of advertising, purpose of trade or for such purposes of a similar nature as it may be deemed Reproductions in any form with or without alterations or omissions by Alpha Phi Alpha Fraternity, Inc. In addition, I consent for the release of any media production related to my voice, picture and/or likeness and  Gather statistical data for evaluation purposes  Assist youth with academic and employment needs I am participating in the Alpha ESQuires Youth Development Program. Release of my educational and employment records to Alpha Phi Alpha Fraternity, Inc. I, (student name) _hereby give consent for the By signing this form you authorize the release of information be entrusted to Alpha Phi Alpha – Delta Alpha Lambda (FERPA) of 1974, HIPPA, and employment confidentiality laws. The Alpha ESQuires Advisory Committee adheres to the Family Education Rights and Privacy Act Granted to external agencies providing funding support to programs if requested. In what other activities are you involved?ĮMPLOYMENT, EDUCATION & MEDIA RELEASE FORMĪll program participants, parents/guardians and Alpha ESQuires Advisory Committee must complete this form as a prerequisite for program enrollment. If necessary, would you be able to attend summer school? _Yes _NoĪre you willing to do community service projects as part of your coursework Have you ever been suspended from school? _Yes _No I have been absent: _1-3 days _5 days _6-10 days _ over 10 days Have you received 1 or more grades of D or F? _Yes _No What are your career and education goals?Ĭlassroom behavior? _Excellent _Good _Poor _BadĪttitude about school? _Excellent _Good _Poor _BadĪttendance performance? _Excellent _Good _Poor _BadĪcademic performance? _Excellent _Good _Poor _Bad How do you think you will benefit from the program? What school subjects do you like least and why? What school subjects do you like most and why? Program _ 4 – Year College _ Workforce _ Military Photograph to be taken for use by the chapter in all fraternal publications and for release to local media outlets. I further give permission for me or my son’s Grant permission for my son, listed above, to participate in all activities provided by the Alpha ESQuires Program. I have read this form and other program documentation and I have read and am voluntarily signing this authorization and release. I understand that this release includes any claims based on negligence, action or inaction of the fraternity, its members, allowing me (and my son) to participate in Alpha ESQuires Program, I understand and expressly acknowledge that I release the DAL Chapter and its membersįrom all liability for any injury, loss or damage connected in any way whatsoever to my son’s participation in the Alpha ESQuires Program, whether on or off the

Therefore, in exchange for Delta Alpha Lambda Chapter of the Alpha Phi Alpha Fraternity, Reasonable precaution is taken, accidents can sometimes still happen. In addition, I (parent) give my son permission to participate in the Alpha ESQuires Program. I (student) 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 PERMISSION FOR ENROLLMENT AND RELEASE FROM LIABILITY Phone: _Įmail: _Ĭurrent Grade Level: Current Cumulative Grade Point A Y o u t h D e v e l o p m e n t P r o g r a mĪlpha ESQuires of Cleveland, OH Membership Application