Alpha Esquires of Southfield Leadership and Mentoring Program
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The Alpha Esquires of Southfield was created to provide a beacon of mentorship to the youth of our community; to offer them guidance and direction on how to be successful in the classroom and within society. We will offer young men of middle and high school age an outlet to develop themselves mentally, physically, emotionally, and socially. This will be done through academic support, community service, enrichment and various activities that focus on brotherhood, mutual respect for men and women and social responsibility.
Over the course of each scholastic year, young men in 6th – 12th grade may apply and based on meeting the requirements, be accepted into the Esquire Mentorship Program. One of the requirements is that each applicant will write a one-page essay explaining why he should be accepted into the program. The essay must also include what he seeks to gain from the mentorship and what he expects to give. Applicants, along with their parent/guardian, will complete a commitment contract to ensure full participation and attendance at each session. All Alpha brothers participating with the Esquires will also complete a commitment contract. Our program curriculum is based on four basic principles:
●Brotherhood
●Leadership
●Scholarship
●Service
These four “pillars” will be interlaced into every activity we plan. We believe that our beloved fraternity, Alpha Phi Alpha has stood upon these very same principles and ideals since its inception in 1906.
Academic, Professional and Leadership Development
Community Service
Financial, physical and mental health education
Complete Application will consist of the following:
●one page essay on "why I want to be an Alpha Esquire?"** (should provide space on application
●most recent Official High School Transcript (most recent report card for students in 6 - 8th grades) with an overall G.P.A. of 2.5 on a 4.0 scale
●provide (2) letters of recommendation
●One from - teacher, pastor, counselor at your current school. (relationship MUST be specified)
●Non-refundable membership fee of $250.00 (due in full by August 1st, 2018)
Mission Statement
To educate, guide, and inspire young males to achieve their greatest potential in the areas of leadership, scholarship, service and brotherhood for the benefit of themselves, their families, and their community.
Membership Application
Applicant Information
Name:Current address:
City: / State: / ZIP Code:
Phone (cell): / Date of Birth: / Email:
Education
Current School:School Address: / Grade (Fall 2017)/GPA:
City: / State: / Zip Code:
Parent Information
PArent/Guardian’s Name:Home Phone: / Cell Phone:
Email Address:
PArent/Guardian’s Name:
Home Phone: / Cell Phone:
Email Address:
All completed application packets MUST be postmarked no later than ____12-2-2017______ and mailed to the
following address:
Alpha Phi Alpha Fraternity Incorporated, Sigma Delta Lambda Chapter
Attn: Alpha Esquires of Southfield
22200 West 11 Mile Road, #2412
Southfield, MI 48037-2412
Social Media Release
My son, ______, has my permission to participate and appear in video/audio recordings, films, photographs, written articles, or on websites and social media sites . This consent includes the use of my child’s image, voice and name in media projects by the Alpha Esquires of Southfield and Alpha Phi Alpha Fraternity Incorporated, Sigma Delta Lambda Chapter to print/broadcast on social media outlets such as newspapers, radio, television stations and news websites.Signature of Parent/Guardian: / Date:
Signature of Parent/Guardian: / Date:
Permission to Travel
My son,______, has my permission to participate in travel on behalf of Alpha Esquires of Southfield for any community service activities or field trips. I release the Alpha Phi Alpha Fraternity, Incorporated Sigma Delta Lambda Chapter from any liability, damages, claims, or causes of action arising from my child’s participation on field trips, except as otherwise provided by law. I assume full responsibility for my child.Signature of Parent/Guardian: / Date:
Signature of Parent/Guardian: / Date:
Health Form
Alternative Emergency Contact
Primary Emergency Contact Name 1:Address: / Phone (cell):
City: / State: / ZIP Code:
Relationship:
Primary Emergency Contact Name 2:
Address: / Phone (cell):
City: / State: / ZIP Code:
Relationship:
Insurance Information
Insurance Company Name:Hospital/Clinic Preference:
Policy No:
Exp. Date:
Physician’s Name: / Telephone:
Allergies/Special Health considerations
Medical History/Info (Optional)
Medical Conditions (Asthma, Respiratory Problems, Heart Murmur, etc):Injuries/Pre-Existing Conditions:
Surgeries:
Current Medication (If applicable):
Please disclose any additional information that would be helpful in case of an emergency.
Confidentiality Agreement
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.Signature of Parent/Guardian: / Date:
Witness: / Date:
If you have any questions or concerns, please contact us at
I hereby certify the information provided in this application is true and correct to the best of my
knowledge and belief. I also understand that any falsified information is sufficient cause for rejection of
this application.
Applicant’s Signature ______Date ______
Parent/Guardian’s Signature ______Date ______
Parent/Guardian’s Signature ______Date ______