Omicron Delta Kappa Membership Application : Student Affairs : UMass Lowell

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Name:
Campus Mailstop:
Date:
Local Address:
Local Phone #:		Email:
Permanent Address:
Permanent Phone#:		Campus ID #:
Anticipated Graduation (Month/Year):		Overall cumulative GPA:
Academic Major:		Academic Minor:
Academic Credits (Total completed as of end of most semester):
Institution(s) attended, if any, other than UMass Lowell (please provide major reason for leaving and Cumulative GPA at that school):

List all collegiate activities in which you have participated; indicate those in which you have received honors and awards and note those positions of leadership or specific responsibilities you have. Please be thorough and include length of service or participation. (Note: you do not need to have been involved in all five (5) areas to qualify for membership.)
I. Scholarship - Membership in honor societies; research projects other than class presentations; conference presentations, dean's lists; etc. (indicate length of participation and position)

II. Athletics - Intercollegiate participation; team manager; captain of intramurals; participants in intramurals; sports club president; sport club officer; sport club participant; intramural or facility supervisor at Recreation Center; etc.(indicate length of participation and position):

III. Community & Campus Activities - Officers of student organizations; members of student organizations; residential life staff, orientation staff, first year resource educators; membership on campus wide committees; committee and volunteer activities; etc.(indicate length of involvement and positions of responsibility.):

IV. Journalism, Speech & The Mass Media - Directors, editors, officers and members of media organizations. DJs, writers, photographers, etc. (indicate length of involvement and positions of responsibility.) :

V. Creative & Performing Arts - Activities in theater, list production and role (stage crew, lights, make-up etc.) lead & supporting performances; musical productions (concerts), organizations/ensembles etc. :

Please provide any additional information that you wish to include:

By submitting this application I, the above named applicant, authorize the release of information necessary for the UMass Lowell ODK Circle to consider my application based upon the requirements for membership as cited in the accompanying letter. I realize this includes my academic transcripts as well as disciplinary records.