Alpha Phi Alpha Fraternity,

Inc.
ALPHA ELITE SERVICE ORGANIZATION
606 SAINT FRANCIS STREET
MOBILE, ALABAMA 36602
APPLICATION
Applicant Information:
Name______________________________________________________________________
Last
First
Middle
Address_____________________________________________________________________
City______________________State________________________Zip___________________
_
Home Phone (
) _________________________Cell (
____________________________

Age________Date of Birth___________/__________/19________________
School________________________________Grade_________________________________
Email_______________________________________________________________________
Parent/Guardian Information:
Name_______________________________________________________________________

Relationship to
Applicant________________________________________________________
Home Phone (___) _________________________Cell (__ )
____________________________

ALPHA ELITE APPLICATION - REVISED MAY 2012

Page 2

Your completed application packet must contain the

following documents:
Have no more than three disciplinary infractions
Two Recommendations from Teachers or Community Leaders (Typed)
Current copy of Transcript
Application Fee of $75 (Non-Refundable)
Current Photo
One page Biographical Essay
1. What are your plans after high school graduation?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. If you are granted an opportunity to join the organization, what would be your
expectations?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. What can you bring to the organization?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Why are you interested in becoming an Alpha Elite?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. List your hobbies and extra-curricular activities.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Mail completed Application along with a current transcript to:

Alpha Elite Service Organization
P.O. Box 2383
Mobile, Alabama 36652

Page 3

EMERGENCY CONTACT INFORMATION

Emergency
Contact___________________________________________________________________
Relation____________________________________________________________________________
Home Phone (__) ______________________Cell (___) _________________Work (___)
___________

Emergency
Contact___________________________________________________________________
Relation____________________________________________________________________________
Home Phone (__) ______________________Cell (___) _________________Work (___)
___________

****Do you have medical conditions? ____Yes_____No

If yes, Please Explain.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Page 4

RELEASE FOR MEDICAL TREATMENT

In the event of an emergency and the inability of the organization to obtain
my consent, I hereby grant permission for the Alpha Elite Service
Organization to authorize any medical treatment or surgery which a
physician or surgeon shall deem necessary for my child.
Parent/Guardian
Signature________________________________Date____________________
Parent/Guardian
Signature________________________________Date____________________

In case of an emergency, which hospital or urgent care facility would you

prefer to have your child transported?
Hospital/Urgent
Facility_____________________________________________________
Primary
Care
(___)_________________

Physicians

Care

Name________________________Phone

PARENTAL ACKNOWLEDGEMENT
I hereby give permission for my child to participate in the Alpha Elite Service
Organization. I understand that the organization is not responsible for
personal injury or loss of property. I understand that my son may leave the
program at any time. I agree to immediately update this application as
changes occur.
Parent/Guardian
Signature__________________________________Date__________________
Parent/Guardian
Signature__________________________________Date__________________

Page 5

HOLD HARMLESS AGREEMENT

The Alpha Elite Service Organization will not be responsible for accidents
pertaining to or other matters related to medical conditions of the applicant
in any form. With the undersigned signature, I confirm that I freely and
voluntarily permit my child to participate in activities associated with the
Alpha Elite Service Organization. I understand that by participating in the
activities, my child may be asked to travel in personal automobiles to attend
events associated with the organization.
I am willingly accepting full
responsibility and liability for any injury which might be suffered during
travels. Therefore, I hereby release and hold harmless, the membership,
programs and services of Alpha Phi Alpha Fraternity from any claim or
liability relating to any injury, including death, which may occur during or as
a result of participating in the program.

___________________________________
_____________________________
Parent/Guardian Signature

Date