Delta Sigma Theta Sorority, Inc.
A Public Service Sorority Founded in 1913
Schaumburg-Hoffman Estates Alumnae Chapter
2017-2018 Educational Programs Application

Applicant's Information

PARTICIPANT 1

First Name

Last Name

T-shirt Size *

Gender

Birth Date +

Name of School *

Grade

Contact Number *

*

Cell Phone

Home Phone

Email Address *

PARTICIPANT 2

First Name

Last Name

T-shirt Size

Gender

Birth Date +

Name of School

Grade

Contact Number

Cell Phone

Home Phone

Email Address

Address Information

Street Address *

City *

State *

Zip Code *

Household / Adult Primary Contact

Relationship to Participant: *

First Name *

Last Name *

Address 1 *

City *

State *

Zip *

Home

Cell Phone

Email Address *

YOUTH PROGRAMS

PARTICIPANT 1

Select a program *

Youth Program Flyer 1

Youth Program Flyer 2

PARTICIPANT 2

Select a program

Dr. Betty Shabazz Delta Academy
Girls Ages 11-14
"Forecast for the Future"
Exploring, Planning & Preparing for our Future
Program designed to prepare young girls for the full
participation as leaders in the 21^st century. Session themes
focus on Science, Technology, Engineering and Math.

G.E.M.S.
Girls Ages 14-18
"My Year of Yes!"
Growing and Empowering Myself Successfully
Program provides the framework to actualize dreams
through the performance of specific tasks that develops a “Can Do”
attitude in the areas of Scholarship, Sisterhood, Finances and Service.

E.M.B.O.D.I.
Males Ages 11-18
Empowering Males to Build Opportunities for Developing Independence
Informal and empirical data suggests that the vast majority of African-American males continues to be in crisis and is not reaching its fullest potential educationally, socially and emotionally. EMBODI is designed to address these issues through dialogue and recommendations for change and action. EMBODI addresses issues related to STEM education, culture, self-efficacy, leadership, physical and mental health, healthy lifestyles choices, character, ethics, relationships, college readiness, fiscal management, civic engagement and service learning.

PROGRAM MEETING DATES & TIMES

ROOSEVELT UNIVERSITY
1400 N. Roosevelt * Schaumburg, IL 60168
Saturdays, 9:30am to 12:30 pm

10/21/17 HBCU College Fair*

1/13/18 Session 1

1/27/18 Session 2

2/10/18 Service Project*

2/24/18 Field Trip*

3/3/18 Session 3

3/10/18 Career Fair

4/7/18 Session 4

4/28/18 Session 5

5/12/18 Finale Party

*HBCU Fair- Elgin Community College
For more information and to register Click Here

REQUIRED ESSAY

Required: Applicant requested to write a short essay. You can type your essay directly into the space provide below or use the file loader to upload your essay.

Essay Question: Why do you want to participate in the Delta Educational Programs? What are your expectations of the programs?

How will you submit your essay?

I would like to type my essay directly into this application

I would like to upload a file

Type your essay directly into this application:

Or Upload your essay (20 MB)

PARENTAL AFFIRMATION

Parent/Guardian must complete and agreee to the Parental Affirmation provided below. After applicant’s acceptance into the program, you will receive a “Welcome Packet” with additional program forms that must be completed before applicant can begin program participation.

* Emergency Contact & Medical Treatment Authorization
* Field Trip Permission
* Photograph and Video Authorization and Release Form
* Youth Pick-Up Authorization Form

I (Guardian) *

under penalty of perjury, do hereby affirm to the Schaumburg-Hoffman Estates Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated that I authorize the participation of ("Applicant Minor Child") *

in the Delta Sigma Theta Sorority, Incorporated Educational Youth programs (including planned activities), and that I have the legal authority to provide my consent and authorization for such participation.

Date: * +

Relationship to Participant: *

Signature: *

clear

WAIVER AND RELEASE

I (Guardian) *

on behalf of ("Applicant Minor Child") *

do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Incorporated (“Delta”), its officers, National Executive Board, employees, members, local chapters, representatives, agents, affiliates, and assigns (collectively “Releasees”), from any and all claims, demands, and actions of any and every kind directly or indirectly arising out of, or relating in any respect to Participant Minor Child’s participation in the Delta Sigma Theta Sorority, Incorporated Educational Youth Initiative programs.

My waiver and release of all claims, demands, actions, and liability shall include without limitation, any injury, illness, death, property damage or loss to the Participant Minor Child which may be caused by any act, or failure to act, by the Releasees, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of any Releasee.

I understand that, without limitation of the foregoing, neither Delta, nor the Program, shall be liable and each is hereby released from all claims that may arise from loss or damage to the Participant Minor Child’s personal property.

Guardian Name: *

PHOTOGRAPH AND VIDEO AUTHORIZATION AND RELEASE FORM

I/We ("Parent/Guardian")

, as parent(s) or legal guardian(s) of

give permission for Schaumburg-Hoffman Estates Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to publish on the Internet or media still photographs or moving images,
including, if applicable any sound recordings accompanying the images (“Images”) taken of my child at the Youth programs sessions, without payment or any consideration and without notifying me.

I/We understand and agree that these Images will become the property of the Chapter, which shall have complete ownership of the Images. I hereby irrevocably authorized the Chapter to publish or distribute these Images for the purpose of publicizing the Chapter’s programs, including the Youth programs or for any other lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my child’s likeness appears. Additionally, I waive any rights to royalties or other compensation arising out of or related to the use of the Images.

I/We hereby hold harmless and release and forever discharge the Chapter and any of its officers and members; Delta Sigma Theta Sorority, Incorporated; its officers; National Executive Board; employees; members; representatives; agents; and assigns from any and all claims, costs, suits, actions, judgments, and expenses which my child, his/her heirs, representatives, executors, administrators, or any other persons acting on his/her behalf have or may have by reason of the use of the Images. This release specifically includes, without limitation, a complete release and discharge of any liability by virtue of any editing, distortion, alteration, or optical illusion, whether intentional or otherwise, that may occur or be produced in the taking of or editing of said Images, unless it can be shown that such was maliciously caused, produced and published solely for the purpose of subjecting my child to conspicuous ridicule, scandal, reproach, scorn and indignity.

I/We hereby certify that I/we are the parents/guardians of

, and do hereby give my/our consent without reservation to the foregoing on behalf of my/our child.

Parent/Guardian Signature 1:

clear

Print Name

Date +

EMERGENCY CONTACT & MEDICAL TREATMENT AUTHORIZATION (PART 1)

Participant's 1 First Name *

Participant's 1 Last Name *

Date of Birth *

Age *

Street Address *

City *

State *

Zip Code *

Gender *

Height *

Weight *

Does your child have Allergies or Sensitivities: *

Allergies/Sensitivities:

	List all types, medications and/or dosage your child receives on a continual basis:
Not Applicable	List all types, medications and/or dosage your child receives on a continual basis:
Food Allergies	List all types, medications and/or dosage your child receives on a continual basis:
Medicines	List all types, medications and/or dosage your child receives on a continual basis:
Bee sting	List all types, medications and/or dosage your child receives on a continual basis:
Insect Bite (Type)	List all types, medications and/or dosage your child receives on a continual basis:
Other	List all types, medications and/or dosage your child receives on a continual basis:

	Asthma		Vision		Hearing		Behavioral
	Inhaler	No Inhaler		Glasses	Contacts		Hearing Aid(s)		ADD	ADHD
Select all that apply	Inhaler	No Inhaler		Glasses	Contacts		Hearing Aid(s)		ADD	ADHD

Participant's 2 First Name

Participant's 2 Last Name

Date of Birth

Age

Street Address

City

State

Zip Code

Gender

Height

Weight

Does your child have Allergies or Sensitivities:

Allergies/Sensitivities:

	List all types, medications and/or dosage your child receives on a continual basis:
Not Applicable	List all types, medications and/or dosage your child receives on a continual basis:
Food Allergies	List all types, medications and/or dosage your child receives on a continual basis:
Medicines	List all types, medications and/or dosage your child receives on a continual basis:
Bee sting	List all types, medications and/or dosage your child receives on a continual basis:
Insect Bite (Type)	List all types, medications and/or dosage your child receives on a continual basis:
Other	List all types, medications and/or dosage your child receives on a continual basis:

	Asthma		Vision		Hearing		Behavioral
	Inhaler	No Inhaler		Glasses	Contacts		Hearing Aid(s)		ADD	ADHD
Select all that apply	Inhaler	No Inhaler		Glasses	Contacts		Hearing Aid(s)		ADD	ADHD

EMERGENCY CONTACT & MEDICAL TREATMENT AUTHORIZATION (PART 2)

Parent/Guardian #1

Name *

Relationship *

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address:

Parent/Guardian #2

#2 Name

#2 Relationship

Address 2:

#2 Street Address

#2 City

#2 State

#2 Zip Code

#2 Home Phone

#2 Work Phone

#2 Cell Phone

If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.

Name

Relationship

Home Phone

Work Phone

Cell Phone

Name

Relationship

Home Phone

Work Phone

Cell Phone

In the event that the Program is unable to reach any of the individuals named above promptly by phone, I/we authorize the Program to seek and secure any emergency medical or surgical care for my/our child. I/We will be responsible for any and all expenses incurred and authorize the medical facility at which treatment is rendered to release all necessary information to my/our insurance company.

Parent/Guardian Signature

clear

Date +

YOUTH CODE OF CONDUCT

Respect all participants (other youth and adult volunteers) by not using foul, hurtful, or obscene language or engaging in physical violence, bullying (including cyber-bullying) or other aggressive behaviors that threaten the safety of others.
Respect the property rights of others. This means do not damage or deface the building or property within the building where chapter activities are held; do not damage or take the personal property of any other participant or volunteer; and do not use Delta’s name or any symbol or logo (Delta’s intellectual property) on any clothing, books, bags, or other items.
Return supplies to their proper place after using them.
Clean up all work areas properly.
Listen carefully to directions and when someone else is talking.
Respect designated quiet areas, such as homework/reading area.
Stay within the program’s designated areas within the building.
Cooperate and participate in organized activities.
Assume full responsibility for all personal belongings. Please leave valuables at home.
Do not bring any weapons, cigarettes/drugs, alcohol, or anyting illegal to any activity at any time.

Sanctions for Violating Code of Conduct

Sanctions for violating the code of conduct may include a verbal warning, loss of privileges, suspension from the program or removal from the program, depending on the severity of the misconduct. If the youth is in possession of an illegal substance or dangerous weapon, police will be notified.

(Student Participant)

With my parent or other adult, I have read the Code of Conduct and sanctions for violating the Code. I understand the Code and the sanctions. I will follow the Code of Conduct.

Parent/Guardian Signature *

clear

Print Name *

Date * +

WAIVER AND PERMISSION TO TRANSPORT YOUTH

Name of Child:

Event:

Location:

Driver:

I give permission for my child/charge ("child") to be transported in a motor vehicle driven by the individual identified to an event at the specific location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver.

I have read, understand and discussed with my child that:

1. They will be traveling in a motor vehicle driven by an adult and they are to wear their safety-belt while
traveling;

2. They are expected to respect the vehicles they ride in, and the person they travel with during the trip;

3. Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by
riders, other drivers or objects; and

4. They are to remain in their seats and not be disruptive to the driver of the vehicle.

I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transporation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Schaumburg-Hoffman Estates Alumnae Chapter from any claim that I might have myself or that I could bring on my child's behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation, I have read this entire waiver and permission form, fully understand it, and agreee to be legally bound by its terms.

Parent/Guardian Signature 1:

clear

Print Name

Date +

Parent/Guardian Signature 2:

clear

Print Name

Date +

OFF-SITE PERMISSION

I/We ("Parent/Guardian") *

, as parent(s) or legal guardian(s) of *

("Child"), give permission for my/our Child to participate in the Schaumburg-Hoffman Estates Alumnae Chapter Youth Initiatives Program's (the "Initiatives") activities taking place offsite. I/we understand that transportation to and from these activities will be provided for my/our Child by the Chapter.

I/We understand that the field trips are part of the Initiatives and if I/we choose to not have my/our Child participate in one or more off-site activities, I/we must make other care arrangements for my/our child during the times of that field trip activity.

I/We assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, expect for gross negligence or intentional infliction of harm by the Initiatives, its officers, agents or employees.

I/We do hereby agree to release and hold harmless the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns from any and all claims, costs, suits, actions, judgements, and expenses for any damage, loss, or injury to my/our child or damage to my/our child's property arising from my/our child's participation in field trips, other than damage, loss, or injury that results from gross negligence or intentional infliction of harm by the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns.

Parent/Guardian Signature 1: *

clear

Print Name *

Date * +

Parent/Guardian Signature 2:

clear

Print Name

Date +

YOUTH PICK-UP AUTHORIZATION FORM (Optional)

I authorize the persons listed below to pick-up my child from the Schaumburg-Hoffman Estates Alumnae Chapter Youth Programs (*If your child is 17 years or older see below). For my child’s safety, I understand that all authorized persons on the list below will be asked to show photo identification before my child is released to them; therefore, I will notify all authorized persons of this requirement so that they will have photo identification with them when they arrive to pick-up my child. (Please include names of either parents or guardians on list below).

Participant's 1 First Name

Participant's 1 Last Name

Participant's 2 First Name

Participant's 2 Last Name

Name

Relationship

Home Phone

Work Phone

Cell Phone

Name

Relationship

Home Phone

Work Phone

Cell Phone

Name

Relationship

Home Phone

Work Phone

Cell Phone

By signing below, I verify that I have read and agree to the Student Pick-Up policies described above and authorize the Schaumburg-Hoffman Estates Alumnae Chapter to release my child to the persons listed above. I also agree to notify the Schaumburg-Hoffman Estates Alumnae Chapter in writing of any changes to the above list of authorized persons.

My child is 17 years or older and I give permission for my child to leave the program on their own after being checked out by an adult program volunteer.

Parent/Guardian Signature

clear

Date +

Signature: *

clear