Alpha Gamma Xi

Membership Application $15 Application Fee Required

APPLICANT INFORMATION
Name:
Date of birth: Home Phone: Cell Phone:
Current address:
City: ZIP Code: Grade Level:

EDUCATION

Please list the classes you took during the Fall 2010 semester. Please include your teacher’s names and room
numbers.

1st

2A

2B

3rd

4th

GUARDIAN CONTACT INFORMATION

Guardian(s) Name:
Home Phone:
Address:
Cell Phone:

City: State: ZIP Code:

Relationship:
ACADEMIC AND DISCIPLINE INFORMATION
GPA Weighted: Un-weighted:
Have you been suspended? If you answered “yes” to the question, please explain here.

REFERENCES
Name Address Phone

PLEASE ANSWER THE FOLLOWING QUESTIONS (TYPED; 12 POINT FONT)

What community service or extra-curricular activities are you currently involved in?
What does being a member of ALPHA GAMMA XI mean to
What are your goals for this school year?
you?
SIGNATURES
Parent/Guardian Signature:
 Long Essay

Alpha Gamma Xi’s motto is “Empowering others

through respect, honor, and merit.” Write an essay
on what this motto means to you and how you plan
to exhibit these valuable character traits in your
everyday life. Also include information about yourself
and shed light on how you will positively impact the
organization.
(Times New Roman; 12 point font; double spaced)

The application fee is non-refundable. The money will be used to help pay for
any necessary items during the ALPHA GAMMA XI membership process.