Krimson Community Foundation Inc.

BEAUTILLION CANDIDATE
APPLICATION FORM
(Please print legibly or type)
APPLICATIONDUE
DUENO
NOLATER
LATER THAN
THAN FRIDAY,
SEPTEMBER,
30, 2016
APPLICATION
SATURDAY,
SEPTEMBER
10, 2016
Name:

Address:

City, State & Zip:

Parents E-mail Address:

Your E-mail Address:

(if different from parents e-mail address)
Mailing address:
(if different from above)
Area code & home phone #:

Your cell phone # (including area code):

Date and place of birth:

Mothers name:

Fathers name:

With whom do you live with? _____ both parents

_____ Mother _____ Father _____ relative

other

High School Information

Name of current high school:

School address:

City, State & Zip:

Area code & phone #:

Classification:

Junior: ____

Senior: ____

Current high school GPA:

(based on 4.0 scale will need current grades/transcripts with official seal when application is
returned)
Do you have any physical limitations (yes/no)?
If yes, what are the limitations? ______________________________________________
______________________________________________________________________________
Outstanding achievements/awards:

Extra curricular activities/Hobbies:

Community Involvement:

Future Plans
College/University/Military/Trade School of interest:

Major/Minor:

__________________________________________________________________________________________

Career Goals:

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________

____________________________________________________________________________________________

WORK EXPERIENCE
(current employer first)

Employer #1:

Date, from/to:

Hours worked per week:

Job description:

Employer #2:

Date, from/to:

Hours worked per week:

Job description:

Employer #3:

Date, from/to:

Hours worked per week:

Job description:

PERSONAL REFERENCES
(Teachers and Administrators Only
Minimum of 3 required)

Name/area code & phone #:

School/position:

Name/area code & phone #:

School/position:

Name/area code & phone #:

School/position:

Name/area code & phone #:

School/position:

Name/area code & phone #:

School/position:

X
Student Signature and Date

STUDENT APPRAISAL FORM

(to be completed by school official)

Please type or print the following:

Students full name:

Your name, title/position & phone #:

How long have you known the student?

Students class rank:

years

months

GPA on 4.0 scale:

Please rate the student in the following categories:

accountability, aptitude, attitude, responsibility & leadership skills:

__________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
X
School Officials Signature and Date

RELEASE FOR MEDICAL TREATMENT

In the event of an emergency and the inability of the Alpharetta/Smyrna Alumni
Chapter or Krimson Community Foundation officers to obtain my consent, I hereby
give permission for the Alpharetta/Smyrna Alumni Chapter of Kappa Alpha Psi or the
Krimson Community Foundation 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____________

Father: Cell Phone: (

Mother: Cell Phone: (

) _______-_____________
) _______-_____________

In case of an emergency, which hospital or urgent care do you prefer to have your child transported?

Hospital/Urgent Care Facility: ____________________________________________

City & State: ____________________________________________
Primary Care Physicians Name: __________________________________________

PARENTAL ACKNOWLEDGEMENT
I hereby give permission for my child to participate in the Krimson Community
Foundation Diamonds Beautillion (the Beautillion). I indemnify and hold the
Alpharetta-Smyrna Alumni Chapter of Kappa Alpha Psi (the Alumni Chapter) and the
Krimson Community Foundation (the Foundation) harmless against any personal
injury or loss or damage to property experienced or caused by my child during his
participation in the Beautillion, including any money collected or raised until such
money is formally tendered to the Alumni Chapter or the Foundation. I also consent
to my child receiving information regarding health, life skills and life choices and
acknowledge that such information may be mature in nature but educationally
appropriate for my child. I further acknowledge that my child and I are committed to
completion of the entire Beautillion program, which culminates April 2017, and we
are responsible for ensuring that my child is in attendance for all Beautillion activities.
I further acknowledge that the registration fee is non-refundable and if my child
leaves the program at any time, then their registration fee will be forfeited. I
agree to immediately update this application when any of the information changes.

PARENT/GUARDIAN SIGNATURE ________________________________________ DATE______________