Apalachee FBLA Local Membership

2018-2019 Application Form

Student Information:

First Name __________________ Middle Name _________________________ Last Name __________________________

Home Telephone #_________________________ Your Cell Phone # ____________________________ Current Grade______

Address ___________________________________________ City ______________ State ________ Zip __________

Student E-Mail ______________________________________ Birth date __________ Student ID # __________

(For National Reporting, please check only one box in each section)
Gender: Male ______ Female ______
Race: ______ African American ______ Hispanic ______ Asian
______ American Indian ______ Caucasian ______ Other

Extracurricular Activities: (clubs, sports, community activities and any leadership role you hold)
__________________________________________________________________________________________________________

Please list your class information for 1st and 2nd Semesters in PENCIL:

1st Semester Teacher’s Name/Rm # 2nd Semester Teacher’s Name/Rm #

1 Block, 1st Semester
st
1 Block, 2nd Semester
st

2nd Block, 1st Semester 2nd Block, 2nd Semester

3rd Block, 1st Semester 3rd Block, 2nd Semester
4th Block, 1st Semester 4th Block, 2nd Semester
5th Block, 1st Semester*Freshman 5th Block, 2nd Semester
6th Block, 1st Semester 6th Block, 2nd Semester

As an FBLA member, I promise to follow the Mission of FBLA, support the goals of FBLA, abide by the code of ethics set by FBLA,
and to uphold the FBLA pledge.

Student Signature: ________________________________________ Date ________________________

Parent/Guardian Information:

Name__________________________________ E-Mail_____________________________ Phone ______________________

Parents: please read and check appropriate statements:

______ I give my student permission to join and participate in the 2015-2016 WBHS chapter of FBLA.
______ I agree to support my student as an FBLA member and will encourage them to be an active member in the organization.
______ I grant permission for my student to receive texts and emails about FBLA related events and upcoming activities.
______ I grant permission for my student’s picture to be used in print and publication to positively promote FBLA.
______ I would like information about chaperoning opportunities available for FBLA fieldtrips
______ I am interested in becoming a Professional Member of FBLA. Please send me additional information.
______ I am interested in being an Advisory Committee Member.

Parent Signature _________________________________________ Date _______________________

(Chapter Advisor/Officer Use Only)

This member has paid dues:  This member has been entered online: 