Vous êtes sur la page 1sur 2

ALPHA APPLICATION FOR LEO CLUB MEMBERSHIP

Both pages of this form must be completed for all Leos under the legal age of majority and returned to the Leo
club advisor who is a member of the sponsoring Lions club. Because it is the responsibility of the sponsoring
Lions club to maintain records on parental/guardian consent for any young person under the legal age of majority
who joins a Leo club, it is imperative that this completed form be kept on file with the sponsoring Lions club.
Completed forms should not be sent to International Headquarters.

SECTION I: APPLICANT INFORMATION


First (Given) Name

Middle Name

Last (Family) Name


Street Address
City

State

Postal Code

Country
Preferred Phone

E-mail

Gender

Year of Birth

Other organizations
of which I am a member
I am a:

New Member

How did you hear about the Leo club?

Transfer Member

Former Member

Member Number
(If unknown, e-mail leo@lionsclubs.org)

Previous Club Name

Previous Club Number

SECTION II: APPLICANT SIGNATURE


I, the undersigned, am in good standing in my school and/or community, and in accordance with the constitution
and bylaws of this club, hereby apply for membership in the
sponsored by the

Leo Club,
Lions Club. I believe the above information to be true

and complete, and I desire membership in this club. I believe I can make a contribution to the club and be worthy of
the friendship of its members. My parent(s)/guardian(s) and I understand that the entrance fee will be __________
and the annual dues will be

. I also understand that, pending parental/guardian consent, my personal

data will be entered into Lions Clubs International member databases and used to facilitate communications with
and between LCI members. Parental/guardian consent section can be found on the second page of this form.

SIGNATURE OF APPLICANT

DATE

SECTION III: FOR LIONS USE ONLY


Copy of completed application added to Leo clubs files

Leo added to club roster via MyLCI

Parental/Guardian consent received

Parental/ Guardian consent approved via MyLCI

APPROVED BY

Leo-50A 1/13

Leo Club Advisor Signature

DATE

Please complete both sides of this form

SECTION IV: PARENTAL/GUARDIAN REVIEW AND CONSENT


I hereby give permission for my child to become a member of the above-named Leo club. I understand that a Leo club is
sponsored by a local Lions club and provides young people with an opportunity to develop their leadership skills while
serving the community. I have been provided with materials relevant to this Leo clubs operations including the name and
contact information of the Leo club advisor, meeting locations and times, types of service projects conducted, etc.
I understand that by participating in this Leo club, my child will be required to attend club meetings and club service proje cts,
and may also be asked to participate in club social events. Such meetings, projects and events may sometimes require
transportation to various locations which may at times be provided by the sponsoring Lions club; in other cases, I may be
asked to provide or arrange transportation for my child to attend these meetings, projects and events. Furthermore, I
understand that by participating in this Leo club, my child may be filmed or photographed at various club meetings, projects
and events. In addition, I understand that my childs personal data will be provided to the sponsoring Lions club and to Lio ns
Clubs International (LCI) headquarters to facilitate communications with and between our members. This information i s to
be used solely to further LCIs Purposes including to unite the clubs in bonds of friendship, good fellowship and mutual
understanding and to conduct its necessary operational activities in accordance with the LCI privacy policy. To view the LCI
privacy policy, you may visit www.lionsclubs.org and enter the phrase Privacy Policy in the search box at the upper righthand corner of the home page.
Please check the appropriate boxes below to indicate the items to which you consent:
I grant permission for my child to be transported to Leo club meetings, projects or events by the Leo club advisor or
a member of the sponsoring Lions club.
I grant permission for my child to be filmed and/or photographed at Leo/Lions club events and meetings, and for
these videos and/or images to be posted on the Lions Clubs International public website at www.lionsclubs.org, the
Lions Clubs International members-only Intranet site (MyLCI), other LCI member databases, the Leo clubs website,
and/or the Lions clubs/districts website.
I grant permission for my childs personal data to be entered into Lions Clubs International member databases and
to be used to facilitate communications with and between LCI members.
By signing below, you indicate that you have read the information outlined in this Leo -50 form, that you agree to your childs
participation in the Leo club, and that you consent to the items you have checked a bove. This signed form should be
submitted to the Leo club advisor and a copy retained for your own records.

Childs Name
Parent or Guardians Name
Street Address
State or Province_

City
Country

E-mail
Signature of Parent or Guardian

Postal Code
Preferred Phone
Date

IMPORTANT NOTE TO SPONSORING LIONS CLUB:


It is the responsibility of the sponsoring Lions club to maintain records on parental/guardian consent for any young person
under the legal age of majority who joins your Leo club. This form should be reviewed and completed by the parent or
guardian for members under the legal age of majority. Please note that when using MyLCI, you will be asked to confirm that
your Lions club has received parental/guardian consent to enter data of any Leos under the legal age of majority.
Leo-50A 1/13