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

Phone E-mail

Gender Date of Birth (MM/DD/YYYY)

I am a: New Member Transfer Member Former Member

Previous Club Name (if applicable) Previous Club Number

How did you hear about the Leo club?

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 Leo Club,
sponsored by the 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 personalize and improve my
membership experience. To understand how LCI uses your personal data, visit [Link] and search the
phrase “Your Privacy”.

SIGNATURE OF APPLICANT DATE

SECTION III: FOR LIONS USE ONLY

Copy of completed application added to Leo club’s files Leo added to club roster via MyLCI (if applicable)

Parental/Guardian consent received Parental/ Guardian consent approved via MyLCI (if applicable)

APPROVED BY DATE
Leo Club Advisor Signature

Leo50-A 10/18 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 club’s 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 projects,
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 child’s personal data will be provided to the sponsoring Lions club and to Lions
Clubs International (LCI) headquarters to facilitate communications with and between our members. This information is to
be used solely to further LCI’s 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 understand
how LCI uses the personal data of its members, you may visit [Link] and search the phrase “Your Privacy”.

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 events and meetings, and for these
videos and/or images to be posted on the Lions Clubs International public website at [Link], the Lions
Clubs International members-only site (MyLCI), other LCI member databases, and other Leo/Lion websites at the
club, district and multiple district levels.
I grant permission for my child’s 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 form, that you agree to your child’s
participation in the Leo club, and that you consent to the items you have checked above. This signed form should be
submitted to the Leo club advisor and a copy retained for your own records.

Child’s Name

Parent or Guardian’s Name

E-mail Phone

Signature of Parent or Guardian 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 if 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. If your club did
not obtain parental/guardian consent of a Leo member who is below the legal age of majority or otherwise is not able to
provide legal consent, you must not share their information with LCI.

Leo50-A 10/18