First Name *

Last Name *

Middle Initial *

Gender *

Child's Age *

Date of birth *

Address *

City *

State *

Postal code *

Name of School *

Current Grade Level *

Favorite Subject *

Why do you feel that the Alexandria-Fairfax (VA) Aviation Program would be a good fit for your participant? *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Phone *

Email *

What is your relationship to the student being considered for the Aviation Program? *

Electronic Confirmation *

BY ACKNOWLEDGING AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Photo Release *

I hereby give permission for my child to be photographed during their participation in the programs sponsored by the Alexandria-Fairfax (VA) Alumni Chapter of Kappa Alpha Psi, Inc. Fraternity. Inc. I understand the photos will be used to keep a journal of activities, to share during powerpoint presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspapers and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Alexandria-Fairfax (VA) Alumni Chapter of Kappa Alpha Psi, Inc.