Elizabeth City State University | Student Life MIPVerificationofProspectiveMembersRequestForm
On behalf of the (organization name), Chapter, we agree not to proceed any further until approval has been received from the Director of Student Life to continue the Membership Intake Process. We will immediately notify the Office of Student Life if a prospective member chooses not to continue with the membership intake process. Prospective Members By my signature below, I hereby authorize the Office of Student Life to request and receive any information needed to complete the processing of my membership into the organization listed above. This includes, but is not limited to the offices of the Registrar, Judicial Affairs, Health Services, and Financial Aid. I hereby consent to have (1) academic records evaluated each semester; (2) have a Greek Pre‐Participation Physical performed by Student Health Services medical staff during MIP (the physical will additionally include a thorough head‐to‐toe skin assessment); and (3) comply with Elizabeth City State University Hazing Policy and the Laws of North Carolina. I hereby consent to the release of the results of the academic records and Greek Pre‐Participation Physical results to the Pan Hellenic Advisor, Vice Chancellor of Student Affairs, and Dean of Students. Also, I attended the Hazing Seminar provided by the Office of Student Life. A copy of this statement bearing my signature will be considered as valid as the original. # Name (Firstname Lastname) Banner ID# Phone # Signature 1 97 2 97 3 97 4 97 5 97 6 97 7 97 8 97 9 97 10 97 11 97 12 97 13 97 14 97 15 97 16 97 Make additional copies as needed. Intake Coordinator: _____________________________ ______________________________ Print Name Signature Date Campus Advisor: _____________________________ _______________________________ Print Name Signature Date Revised (1/30/2015)