Fill - Free fillable Alpha Kappa Alpha Sorority, Incorporated Undergraduate Membership Interest (City of Oakland) PDF form

III-11

Undergraduate MIP Manual (November 2010)

Alpha Kappa Alpha Sorority, Incorporated Undergraduate Membership Interest Application

(This form must be signed in the presence of a licensed notary. See page III-14 of the application)

I understand that falsification of any information on this application or attachments will eliminate me from being considered for

membership into Alpha Kappa Alpha Sorority, Incorporated

___________________________________________________ _________

Chapter of Interest Date

__________________________ _________________________ _________

College/University City/State Country

___________________________ ______________ __________________

First Name Middle Initial Last Name

_______________________ _______________________ _____________

Home Phone Work Phone Cell Phone

_____________________________ ______________________ ________

Permanent Address City/State Zip

_____________________________ ______________________ ________

School Address City/State Zip

_____________________________________________________________

Email Address

______________________________________ ______________________

List any college organization affiliation Position held, if any/When

______________________________________ ______________________

List any college organization affiliation Position held, if any/When

1. List any academic honors received in the last two (2) years. Please include

when and where.

_____________________________________________________________________

2. List any activities that have allowed you to serve as a role model for girls and/or

women on your campus or in your community:

________________________________________________________________

3. How have you helped to alleviate problems concerning our young girls and

women on your campus or in today’s society?

________________________________________________________________

1. Do you have prior knowledge of Alpha Kappa Alpha Sorority, Incorporated?

Yes ___ or No ___

2. In your own words, describe the purpose of Alpha Kappa Alpha Sorority.

________________________________________________________________

3. What talents do you possess that will ensure that Alpha Kappa Alpha Sorority

will maintain its status as the premier Greek-lettered service organization for

college-trained women?

________________________________________________________________

CHAPTER INFORMATION

PERSONAL INFORMATION

ACADEMIC BACKGROUND

ORGANIZATIONAL KNOWLEDGE

ACADEMIC BACKGROUND (cont’d)

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Undergraduate MIP Manual (November 2010)

4. Please list one program you would implement as an undergraduate member

of Alpha Kappa Alpha Sorority. Describe the target audience and purpose.

________________________________________________________________

When placed in a tense situation…

1. How do you exercise good manners?_______________________________

________________________________________________________________

2. How do you handle conflict?

________________________________________________________________

3. How do you strive to create a supportive environment?

________________________________________________________________

1. Have you received and read the General Information for the Collegian

Brochure? Yes ____ or No ____

2. Have you been a member of a sorority which belongs to the National Pan-

Hellenic Council or National Panhellenic Conference?

Yes____ or No ____

If you answered Yes to No. 2, please name the sorority/sororities and your

initiation date(s).

_____________________________________________________________

Name of Sorority/Sororities Date(s) of Initiation(s)

3. Have you previously applied for membership into a sorority that belongs to the

National Pan-Hellenic Council or National Panhellenic Conference?

Yes ____ or No ____

If you answered Yes to No. 3, please name the sorority/sororities and explain

why you did not pursue membership with that sorority/sororities.

______________________________________________ ________________

Name of Sorority/Sororities Date of Application(s)

______________________________________________ ________________

4. Have you read Alpha Kappa Alpha Sorority’s Anti-Hazing Policy?

Yes ____ or No ____

5. Do you understand Alpha Kappa Alpha Sorority’s Anti-Hazing Policy?

Yes ____ or No ____

6. Have you ever participated in or been accused of hazing as it relates to Alpha

Kappa Sorority, Incorporated? Yes ____ or No ____

7. Have you previously applied for membership into Alpha Kappa Alpha Sorority,

Incorporated? Yes ____ or No ____

8. If you answered Yes to No. 7, please list the following:

______________________________________________________________

Name of chapter Name/Location of Institution Year

______________________________________________________________

Name of chapter Name/Location of Institution Year

9. Have you ever participated in or been accused of hazing as it relates to any

organizations? Yes ____ or No ____

_______________________________________________________________

PERSONAL ASSESSMENT

AFFIRMATION STATEMENT

AFFIRMATION STATEMENT (cont’d)

ORGANIZATIONAL KNOWLEDGE (cont’d)

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Undergraduate MIP Manual (November 2010)

10. Have you ever been convicted of a felony?

Yes ____ or No ____

General Disclaimer to All Applicants: Do not answer “Yes” and disclose any

instances of arrests; any misdemeanor convictions; or any convictions that have

been expunged, annulled, sealed, statutorily eradicated, pardoned, or dismissed

upon condition of probation.

Disclaimer to California Applicants: Do not answer “Yes” if the felony

conviction was related to marijuana and such conviction is more than two (2)

years old.

Disclaimer to Connecticut Applicants: Do not answer “Yes” if the record of

felony conviction was erased under Connecticut General Statutes Sections 46b-

146 (records related to determinations of “delinquency” or that, as a child, you

were a member of a family with service needs), 54-76o (records related to a

ruling that the applicant was a youthful offender), or 54-142a (records related to

a finding that the applicant was not guilty for a criminal charge or a conviction

for which the applicant has received an absolute pardon).

Disclaimer to Massachusetts Applicants: Answer “No or No Record” if you

have a sealed record with the commissioner of probation with respect to any

inquiry relative to prior arrests, criminal court appearances, or convictions.

Disclaimer to Washington State Applicants: Do not answer “Yes” if the

conviction is more than seven (7) years old.

If you answered Yes to No. 10, please describe the circumstances.

________________________________________________________________

1. List the URL of any websites that depicts you in a personal or professional

manner.

________________________________________________________________

Please read carefully before signing the following

As part of the membership application process, Alpha Kappa Alpha Sorority,

Incorporated will conduct a background check on you. Such a process requires your

permission for Alpha Kappa Alpha Sorority, Incorporated to obtain your consumer

report from a consumer reporting agency. You will be responsible for the cost

associated with obtaining your consumer report. Your consumer report, may

include, but not be limited to, the following information: a credit report, consistent

with applicable federal, state and local laws, that includes obtaining information on

convictions and/or pending prosecutions; Department of Motor Vehicles

information; civil suits and judgments within the past seven (7) years; accounts in

collections within the past seven (7) years; and bankruptcies within the past ten (10)

years.

I, ________________________________, hereby

authorize

Name of Candidate (Please Print)

Alpha Kappa Alpha

Sorority, Incorporated to conduct a background check and to investigate my

qualifications as they relate to my becoming a member in the organization for which

I am applying.

I understand that Alpha Kappa Alpha Sorority, Incorporated may utilize an outside

firm or firms to assist it in checking such information, and I specifically authorize

such an investigation by information services and outside entities of Alpha Kappa

Alpha’s choice.

I agree to release and hold harmless Alpha Kappa Alpha Sorority, Incorporated

from any and all liability with respect to receipt of such information and

acknowledge that Alpha Kappa Alpha Sorority, Inc is relying on third party

information and, therefore, release Alpha Kappa Alpha Sorority, Incorporated, its

agents, officers, and employees from any and all liability arising out of errors or

omissions.

I also understand that I may withhold my permission and that in such a case, no

investigation will be done, and my application for membership may not be

processed further.

___________________________________________________ _____________

Signature of Candidate Date

AFFIRMATION STATEMENT (cont’d)

BACKGROUND CHECK

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Undergraduate MIP Manual (November 2010)

Please read carefully before signing the following

I, __________________________________ affirm that the information

Name of Candidate (Please Print)

provided in this application and all submitted documentation is true and correct.

I acknowledge that I have read, understand and will abide by the policy of Alpha

Kappa Alpha Sorority, Incorporated, which forbids hazing. The candidate and

parent(s) or guardian(s) for candidates under the age of twenty-one (21) further

agree to indemnify and/or hold harmless for any and all acts of hazing in which

the candidate participates and which result in harm to the candidate or anyone

else from this day forward in perpetuity.

Alpha Kappa Alpha Sorority, Incorporated has a strict policy against hazing.

Hazing may include, but is not limited to: attending unauthorized rush meetings

or sessions; removing garments; eating or drinking anything given to you as a

requirement for membership in Alpha Kappa Alpha Sorority, Incorporate; or

being subjected to any form of verbal, physical or mental harassment, or

intimidation. Alpha Kappa Alpha Sorority, Incorporated’s requirement is that

those interested in membership in Alpha Kappa Alpha Sorority, Incorporated,

will support our policy against hazing, harassment and/or humiliation of any

kind.

Anti-Hazing Policy

___________________________________________________ ____________

Signature of Candidate Date

Candidate’s Date of Birth _____________________

___________________________________________

Name of Parent or Guardian (Please Print)

____________________________________________________ __________

Signature of Parent or Guardian Date

I, __________________________________ affirm that I understand and agree

Name of Candidate (Please Print)

that any grievances and all disputes brought by prospective members resulting from

claims for personal injury, claims for damages to property, or disputes of any nature

that cannot be resolved within the Sorority, including those arising from the

membership intake process, will be referred to arbitration. Any grievances and

disputes regarding membership intake should be referred to the Regional Director

for investigation and resolution. The prospective member specifically agrees to

follow all of the rules, regulations, and guidelines relating to the intake process. The

prospective member further agrees to report in writing any infractions and

violations of the rules, regulations, and guidelines relating to the intake process. The

prospective member acknowledges that Alpha Kappa Alpha Sorority, Incorporated

is an international organization with entities located throughout the

United States

of America and abroad. The prospective member recognizes by making this

application for membership she agrees to the foregoing matters. The prospective

member understands that this agreement has an effect on interstate commerce and is

subject to the

Federal Arbitration Act. The prospective candidate, her heirs and

assigns, and Alpha Kappa Alpha Sorority, Incorporated, its officers, employees,

agents, affiliates, chapters and members, agree that any and all disputes, conflicts,

claims, and/or causes of action of any kind whatsoever, including but not limited to:

contract claims,

personal injury claims, bodily injury claims, injury to

character claims, and

property damage claims arising out of or relating in any

manner whatsoever to membership of Alpha Kappa Alpha Sorority, Incorporated or

to the membership intake process shall be subject to and resolved by compulsory

and binding arbitration under the

Federal Arbitration Act, 9 U.S.C. Section 1,

et seq., and the commercial rules of the American Arbitration Association.

NOTE: THIS SECTION OF THE DOCUMENT MUST BE SIGNED IN THE

PRESENCE OF A LICENSED NOTARY

__________________________________________________ _______________

Signature of Candidate Date

__________________________________________________ _______________

Notary Seal and Signature Date

ANTI-HAZING POLICY

AGREEMENT TO ARBITRATION

III-15

Undergraduate MIP Manual (November 2010)

INSTRUCTIONS

Please record information below regarding your involvement in community/campus

activities or programs that have occurred within the last two

(2) years

. All

applicants must submit at least one (1) but cannot exceed three (3) ECCI forms to

be considered for membership in Alpha Kappa Alpha Sorority, Incorporated.

Additional documentation should not be submitted and subsequently will not be

reviewed.

This form should be completed in its entirety and any information

documented without signatures will not be accepted.

___________________________________ ________________ ___________

Title of Activity or Program Start Date End Date

__________________________________________________ _____________

Location of Activity/Program # of hours completed

Goal of Activity/Program:

________________________________________________________________

Population Served (check all that apply):

Youth ___ Adults ___ Seniors ___ College Students ___

Other (Please Specify)___________________

Please describe your specific involvement:

________________________________________________________________

1. How did the program positively impact the population served?

_______________________________________________________________

2. Did you meet the goal of the activity/program? Please explain.

_______________________________________________________________

3. How did your involvement in the program affect you?

_______________________________________________________________

By signing this form, I verify that all of the information I have provided is true

and correct. I understand that at any time, Alpha Kappa Alpha Sorority,

Incorporated can rescind any rights or privileges to an applicant based on the

submission of false information or documents.

______________________________________________ ___________________

Signature of Candidate Date

______________________________________________ ___________________

Name of Supervisor (Please Print) Title

_________________________/_____________________/___________________

Email Address Work Phone State and Zip

______________________________________________ ___________________

Signature of Supervisor Date

EVIDENCE OF COMMUNITY/CAMPUS INVOLVEMENT (ECCI) FORM

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