Alpha Phi Alpha Fraternity, Inc.
Eta Theta Lambda Chapter

Eta Theta Lambda Education Foundation

2017 College Tour Application
Please complete all sections of this application.  Your application will not be officially logged
in until a $125 deposit is received.  You may pay the deposit by credit card using PayPal.  Or
you may submit a check made payable to ETL Education Foundation and send to:

ETL Education Foundation
P.O. Box 501
West Hempstead, NY 11552
STUDENT INFORMATION
Last Name*
First  Name*
Street Address*
Apt. #
City*
State*
Zip Code*
Home Phone*
Student Cell Phone*
Student Email Address
Male
Gender
Parent Email Address
Female
How did you hear about
the college tour?
Date of Birth
mm/dd/yyyy
School Name
Academic Average
School Class Status as of 9/1/17
Standardized Test Completion
Verbal
Math
Writing
Please provide your preferred Tee Shirt size
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:
Relationship:
Guardian Address
(type "same" if as above
Guardian Home Phone
Guardian Work or Cell
Phone
Emergency Contact Other Than Guardian
Relationship:
Contact Phone
Student Medical History and Authorization
Medical Insurance Coverage Information
(Medical insurance is required for all tour participants)
In case of an emergency where it becomes necessary for my child to be treated by a hospital or
physician, the medical insurance coverage is as follows:
Name of Insured:
Relation to Child:
Carrier:
Policy ID#:
Employer or Group:
Group #:
Are you currently under a physician's care?
Yes
No
Are regularly scheduled appointments required?
No
Yes
(if yes, please list condition(s) for which you are being treated.)
List any medication your are taking and the reason.
Have you had any contact with Hepatitis or other
contagious illness? (If yes, list illnesses and dates)
Yes
No
Do you have or have you had any of the following during the past year?
Persistent Cough

Shortness of Breath

Chest Pain

Palpitations

Swollen Ankles

Abdominal Pain

Hernia
Fainting

Dizziness

Numbness

Asthma

Joint Pain

Back Pain

Frequent  
Colds
Nervousness

Weight Loss

Difficulty Voiding

Frequent Vomiting

Persistent Diarrhea

Constipation

Eye Problems

Diabetes
Do you have any allergies?  If yes, please list.
Yes
No
                 PARENTAL CONSENT AND MEDICAL STATEMENT
I do hereby give permission for my child to participate in the Alpha Phi Alpha Fraternity, Inc, Eta
Theta Lambda Chapter 2017 College Tour.  It is expected that my child will remain with the
group during the entire tour and he/she will abide by the rules applying to conduct in effect
during the tour.
 In the event that it may become necessary to have my child returned home for
any reason (medical, disciplinary, etc.) while on the tour, transportation costs will be at my
expense.  

I have also read the completed "Medical History."  The above medical record for my child is
thorough and accurate to the best of my knowledge.