The Delta Kappa Gamma Society International

Chi State

Awards and Recognitions Committee

CHI STATE HOSTELSHIP APPLICATION

I.  Personal Data

Name Phone ( )

Address Email

City State _____ Zip

II.  Completed Elderhostel/Road Scholar Program

Program Title ______

Place of Study Dates

Program Topics

III.  The Delta Kappa Gamma Society International, Chi State

Chapter Area

Date of Membership in Chi State ______

Type of Membership: Active Reserve Honorary

IV. Have you received a Chi State Hostelship before? If yes, date

V. List offices held and services rendered at Chapter and/or state level:

a.

b.

c.

VI.  Describe the presentation/s you have made or will make as a result of the Elderhostel/Road Scholar experience.

Chapter President’s name Date

Include the following: Send this application to:

·  One page summary of experience Jill Swaim

·  One or more photos of the trip 832 A Kalpati Circle

·  One small photo of yourself Carlsbad, CA 92008

·  Copy of registration confirmation including (H)760-637-5370 (C)805-766-7430

cost of program (not including airfare)

DEADLINE: December 1

(Application documents will not be returned. Please retain a copy.)

July 2014