EmailMe Form - Walden Campus Civitan

Date Time *

MM / DD / YYYY

Campus Civitan Club

Name *

First Last

Student ID # (A0#) *

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

School Email *

Personal Email *

Expected Graduation Date (Month/Year) *

Degree Program (Ex. BS Child Development, MBA, PhD in Psychology, etc.) *

Other organizations/activities *

Birthdate

MM / DD / YYYY

Gender (Optional)

Male

Female

Are you a former Civitan, Junior Civitan, or Campus Civitan? *

Yes

No

If yes, what club? *

City/State/Province of previous club *

Are you interested in learning more about the following positions?
- Board of Directors
- Recruiting Director
- President
- Vice-President
- Secretary/Treasurer
- PR Chair
- Service Project Chair
- Other *

Yes

No

If yes, which positions?

Anti - Hazing Training Acknowledgement

Walden has zero tolerance for Hazing. Hazing is defined as any action taken or situation created through coercion or otherwise which, regardless of intent or consent of the participants, may reasonably produce substantial risk of causing bodily harm or danger, mental or physical discomfort, embarrassment, harassment, fright, humiliation or ridicule, or otherwise compromises the dignity of an individual; compels an individual to participate in an activity that is unlawful and/or contrary to University rules, policies and regulations; will unreasonably or unusually impair an individual’s academic efforts, and occurs on or off campus between two or more people who are affiliated with the institution including at non-sanctioned events.

Walden University will provide students with an education program on hazing which will be offered online during new student orientation session and as modules that can be taken on -demand prior to Residencies and before joining a new student organization. Organizations are prohibited from accepting or initiating students who have not attended the program.
All staff and volunteers who coach an organization recognized by and operating under the sanction of Walden University and have direct contact with students must have mandatory training on hazing, including awareness, prevention and the institution’s policy.

Copy and Paste Training Link: https://bit.ly/Anti-HazingTraining *

I will complete the Anti-Hazing Training and understand that my application to join this student organization will not be approved until after I complete the training.

Completed By New Members Only
I hereby request membership in the _Walden University Online Campus Civitan Club. Upon acceptance, I agree to be subject to its Constitution, Bylaws, and official policies. I agree to pay the sum of $5 as an initiation fee, in addition to $20 annual club and Civitan International dues. I understand that $1.25 of the Civitan International annual dues applies to liability insurance. You will be directed to pay the dues on the next page.

$20 Annual Club Dues (non-refundable)
$5 One Time Initiation Fee (non-refundable) *

Clear

Please sign with your finger or mouse.

Completed By Former Junior Civitans,
Transfers, or Reinstated Members Only
I hereby request membership in the _ Walden University Online Campus Civitan Club. Upon acceptance, I agree to be subject to its Constitution, Bylaws, and official policies. I agree to pay $20 annual club and Civitan International dues I understand that $1.25 of the Civitan International annual dues applies to liability insurance, and that my initiation fee is waived. You will be directed to pay the dues on the next page.

$20 Annual Club Dues (non-refundable) *

Clear

Please sign with your finger or mouse.

NOTICE: It may be helpful for you to copy and paste these instructions to a word document or take a picture of the instructions to reference.

After you submit this form, you will be re-directed to the Walden University Payment Portal to pay your $25 (non-refundable) membership fee.

Please note your application will not be processed without paying the $25membership fee.

Payment Instructions:
1. After you submit this form, you should be redirected to your Walden Payment Portal.
2. Click on Make a Payment.
3. Scroll down and click on Student Organizations.
4. Choose Walden Campus Civitan Initial Dues.
5. Make the payment as indicated.

Typed Signature *