Kappa League Student Enrollment Form

Please provide a recent headshot of your child

Drag & Drop Files, Choose Files to Upload

Student Name *

First

Middle

Last

Student Email *

Confirm Email

Student Mobile Phone

Student Birthday *

Current School *

Current Grade Level *

Primary Parent or Guardian *

First

Last

Primary Parent/Guardian Email *

Primary Parent/Guardian Phone *

Secondary Parent or Guardian

First

Last

Secondary Parent/Guardian Email

Secondary Parent/Guardian Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Save and Resume Later

Waivers

Accident Waiver

I hereby authorize the student participant (my child),  to participate in organized workshops and activities, realizing that such activities may involve the potential for injury which is inherent in all activities. I acknowledge that such injuries can be severe as to result in total disability, paralysis, or even death.   In consideration of permission granting the student participant to participate in workshops and activities, I hereby release and discharge the Norristown Alumni Chapter of Kappa Alpha Psi® Fraternity, Inc., its members, volunteers, and trustees from all claims, demands, actions, judgments, and executions which the undersigned individually and on behalf of the student participant, ever had, or now has, or may have, or claim to have, against Kappa Alpha Psi® Fraternity, Inc., the Norristown Alumni Chapter, it's members, volunteers or facilitators, for all personal injuries, known or unknown, and injuries to property real or personal, caused by , or arising out of, the above described workshops and activities.   I, the undersigned, having read this warning and release, and understanding all its terms, will not hold Kappa Alpha Psi® Fraternity, Inc. liable for any injuries, disabilities, or the death of the student participant, caused by his participation in the above-described workshops and activities. I execute this release voluntarily and with full knowledge of its significance.

Parent or Guardian *

First

Last

Please type your first and last name

Date *

Name Student Date

Signature of Parent or Guardian *

Clear Signature

Please sign your name

Photo/Video Waiver *

I hereby grant permission to the Norristown Alumni Chapter for the student participant (my child) to appear in or on the following: brochures, videos, newsletters, radio talk shows, television ads, etc., all of which are used to promote the program. I understand that such promotions will be in keeping with the mission and educational philosophy of Kappa Alpha Psi® Fraternity, Inc. and that the Norristown Alumni Chapter reserves the right to utilize such material in current and future promotional projects.

Payment

The cost per student is $75 for the program year. Please remit your payment below.

Add Text and Images to Your Form With Ease

To get started, replace this text with your own.