H/L Kappa League Application 2023-2024

Hyattsville/Landover (MD) Alumni Chapter of Kappa Alpha Psi Fraternity, Inc.
Kappa League

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Student Information

First Name *

Middle Name

Last Name *

Suffix

Street Address *

City *

State *

Zip Code *

Cell Phone

Home Phone

(You must list either a cell phone number or a home phone number)

Email Address *

Grade *

Age *

Gender *

Date of Birth * +

Cumulative GPA *

Shirt Size (Adult Male) *

Number of Brothers *

Number of Sisters *

High School *

If Other, please type name of school

School Address

List the Courses enrolled in this semester

Class 1

Class 2

Class 3

Class 4

Class 5

Class 6

Class 7

Class 8

Course enjoyed most? *

Course enjoyed least? *

What colleges, universities or other schools would you like to attend? (Seniors must complete this section with 6 choices. Others may stop at 3 choices.)

College/School 1

College/School 2

College/School 3

College/School 4

College/School 5

College/School 6

Have you ever been a member of the Kappa League Program? *

If so, what year?

How did you find out about our Kappa League program? *

Parent Information

Mother/Guardian Name

Mother/Guardian Email Address

Mother/Guardian Cell Phone

Mother/Guardian Home Phone

Mother/Guardian Work Phone

Father/Guardian Name

Father/Guardian Email Address

Father/Guardian Cell Phone

Father/Guardian Home Phone

Father/Guardian Work Phone

Tell Us About You

Describe yourself using adjectives *

Do you participate in any school sports? If so, which ones?

Are you involved in any other extracurricular activities, programs, or organizations? If so, What are they?

What do you like to do for fun? Include involvement in intramural or community sports programs,
playing musical instruments, craftwork, outdoor activities, video gaming, etc.

Describe your leadership ability and list clubs, organizations, and/or affiliations that you have been
a leader.

List awards, certificates, recognitions that you have received within the last year:

Essay on Leadership

Please type an essay, not less than 3 paragraphs, on the topic “What Leadership Means to Me”. Include how you have shown leadership, or how you will show leadership, and how you think Kappa League can help you become a better leader. The essay can be typed MS Word or similar compatible software and uploaded here.

Emergency Contact Information (other than parent or guardian)

Emergency Contact Name *

Emergency Contact Phone *

Physician/Nurse Practitioner Name *

Physician/Nurse Practitioner Phone *

Health Insurance Provider *

Health Insurance Policy No. *

Does the participant have any health issues? *

Participants who have health issues such as allergies or other illness, take medication (prescription or over-the-counter), or use emergency medical devices such as inhalers or Epi-pens should answer Yes.

If you answered Yes, the Participant Health/Medication Profile Form must be downloaded (from our website or from email), completed and emailed to info@hlkapsi.org one (1) week after the Kappa League Program Application is due. If you answered No, you will not need to complete the Participant Health/Medication Profile.

Has the participant been immunized? *

Participants who are enrolled in a Maryland public or private school should answer Yes. If the answer was No, or the participant was home-schooled or is enrolled in school outside of Maryland, then the MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE is required. Email the completed certificate to info@hlkapsi.org no later than one (1) week after the Kappa League Program Application is due. The form can be downloaded at:

https://phpa.health.maryland.gov/OIDEOR/IMMUN/Shared%20Documents/MDH_896_form.pdf

Consent Forms

Please upload in one file the signed and dated consent forms which include 1. PARTICIPANT RELEASE AUTHORIZATION, 2. ACTIVITY/PROGRAM FIELD TRIP LIABILITY RELEASE/AUTHORIZATION, 3. PARTICIPANT ACKNOWLEDGMENT and 4. KAPPA LEAGUE PROGRAM POLICY CERTIFICATION. Consent forms can be found on the chapter website and/or will be included in the email shared with you. *

Transcript

Please upload a copy of the Kappa League Candidate's transcript or final report card from the 2022-2023 academic year. *