Nu Alpha Kappa Fraternity, Inc. Iota Chapter
Intake Process Application - Please fill out carefuly
First Name: *
Last Name: *
Current Address: *
City: *
Hometown Address: *
Hometown City: *
Cell Phone: *
Home Phone: *
E-mail: *
Fathers Name: *
Mothers Name: *
Hobbies: *
Goals/Interests: *
Organizations/Clubs: *
How did you hear about us? *
What are you seeking in an organization? *
#1 Reference Full Name: *
Phone: *
Relationship: *
Relative
Friend
Coworker
Other
#2 Reference Full Name: *
Phone: *
Relationship: *
Relative
Friend
Coworker
Other
#3 Reference Full Name: *
Phone: *
Relationship: *
Relative
Friend
Coworker
Other
Employment Status: *
Full-Time
Part-Time
Not working
If working, employer name:
Address:
City:
Hours Per Week:
> 10 hrs
10 - 20 hrs
20 - 30 hrs
30 - 40 hrs
40 +
Upload Resume: *
I certify that my answers are true and complete to the best of my knowledge. If this application leads to acceptance, I understand that false or misleading information in my application or interview may result in my release. *
I Accept
I Decline
Are you currently seeing a health care provider for any ongoing medical conditions? *
Yes
No
If so, please explain and provide the names of all associated health care providers:
Do you currently have any physical conditions (such as diabetes, asthma, back pain or heart condition), medications or dietary restrictions that your Activity Director should be aware of? *
Yes
No
If yes, please explain:
Have you ever been treated for any psychological conditions (anxiety, depression, eating disorder, etc.), which may affect your ability to travel or take part in group activities? *
Yes
No
If yes, please explain:
Please list all allergies, including medication, food, animals, plants or seasonal: *
Please list all prescriptions and supplements that you plan to continue while traveling: *
Please list any other physical or mental conditions that you think the Activity Director should be informed of. If you have any ailments that may restrict activities, please explain: *
Emergency Contact Name: *
Phone: *
Emergency Contact Name: *
Phone: *
I authorize the Nu Alpha Kappa to disclose any information provided on this form, if it is needed for any medical treatment I might undergo while traveling. I understand that Nu Alpha Kappa will maintain this information in confidence and will only release this information to the Activity Directors and/or Medical Personnel in the event of an emergency. I also understand that this information will only be maintained for the duration of my participation in the program. *
I AGREE
I DECLINE
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