Dr. Betty Shabazz Delta Academy Program “Catching the Dreams of Tomorrow, Preparing Young Women for the 21st Century” HATTIESBURG ALUMNAE CHAPTER DELTA SIGMA THETA SORORITY, INCORPORATED www.deltasigmatheta.org www.hattiesburgdst.org Dear Parent(s) and Applicant: Delta Sigma Theta Sorority, Inc. is an international public service organization committed to the principles of sisterhood, scholarship and service. Locally, the Hattiesburg Alumnae Chapter provides an array of public service programs including scholarships for eligible high school seniors, support for Habitat for Humanity, community awareness of health care disparities, voter registration drives, and the Dr. Betty Shabazz Delta Academy. Thank you for your interest in becoming a member of Dr. Betty Shabazz Delta Academy Program. Delta Academy is one of our sorority’s National Youth Initiative programs sponsored by Hattiesburg Alumnae Chapter, serving girls ages 11-14. Our mission is to enable young girls to develop an interest in Science, Math, and Technology. We also strive to foster a sense of community service and build self-esteem in each member. Please see the attached guidelines and membership application necessary for completion regarding membership in Delta Academy. The completed application packet must be RECEIVED by mail on Friday, October 3, 2014. Please return this application packet to: Delta Sigma Theta Sorority, Inc. Hattiesburg Alumnae Chapter Post Office Box 17347 Hattiesburg MS 39404-7347 ATTN: Delta Academy, Monét Ducksworth If you have any questions or concerns, you may contact the Committee Chair, Monét Ducksworth at dacademy@hattiesburgdst.org. A complete application packet includes the following: the attached application, a copy of birth certificate, copy of last report card, Recommendation form, and a picture of the applicant. Please place the packet in a large clasp envelope and mail to the address listed above by the deadline. Note: Parental permission for participation is required for membership. Also, the documents submitted will not be returned to any applicant and incomplete packets will not be accepted. Tawnya Holliman, President Hattiesburg Alumnae Chapter Dr. Betty Shabazz Delta Academy program focuses on the following: 1. Developing interests in math, science, and computer technology 2. Exposing young ladies to non-traditional careers in the areas listed in #1 3. Providing exposure to public service involvement 4. Encouraging educational and cultural enrichment 5. Helping to achieve academic excellence 6. Heightening social graces 7. Stressing the importance of proper health 8. Emphasizing the dangers of drug usage 9. Developing leadership skills and building self-esteem 10. Promoting healthy relationships with peers and Delta members Membership Guidelines: • • • • • • • • • Female ages 11-14 One must exemplify good conduct Maintain a minimal of a C-average in all classes Submit a copy of report card no later than two weeks of school’s distribution Attendance/promptness of all Delta Academy meetings/activities (no more than 2 unexcused absents) No pregnancies and/or applicants with children No dual membership in another Greek sponsored organization If accepted, parents will be responsible for some activity fees and cost Parents will be responsible for transporting and picking up the member in a timely manner ****Guidelines will be strictly enforced (no exceptions)**** Requirements for application review: 1. 2. 3. 4. 5. 6. Complete application (must be signed) Copy of last report card Recommendation letter from a core teacher, principal, and/or counselor Copy of birth certificate to verify age (copy only) Photograph of the applicant Completed application packet must be received by Friday, October 3, 2014. Signature of Applicant: ________________________________________ Date: ___________ Signature of Parent: ___________________________________________ Date: ___________ DR. BETTY SHABAZZ DELTA ACADEMY PROGRAM “Catching the Dreams of Tomorrow, Preparing Young Women for the 21st Century” APPLICATION DATE ____________________ Name: _______________________________________________________ DOB: _____________ Age: _________ Grade: __________ Address: __________________________________________________________ City, State, Zip code: ________________________________________________ Telephone: (Home) ________________ Cell (if applicable) ______________ E-mail address, if applicable: ____________________________________ School Name: (Please give FULL name) ____________________________________ Address: _____________________________________________________ Favorite School Subject(s): _____________________________________________ __________________________________________________________________ Extra-Curricular Activities and Hobbies: __________________________________________________________________ __________________________________________________________________ What would like to achieve from participating in Delta Academy? __________________________________________________________________ __________________________________________________________________ Talent(s) (singing, dancing, drawing, public speaking, sports etc) ______________________________________________________________________________ ________________________________________________________ Church Affiliation: (if applicable) ___________________________________________ __________________________________________________________________ Future Goal(s): _____________________________________________________ How did you find out about Dr. Betty Shabazz Delta Academy Program? PARENTAL/LEGAL GUARDIAN INFORMATION Name: _______________________________________Relationship: __________ Address: _____________________________________________________ City, State, Zip Code: __________________________________________ Telephones: Home______________ Work: ______________ Cell ___________ Emergency Contact: Name: ____________________________________ Contact Number ___________________________ Name:___________________________________ Contact Number ___________________________ Name:___________________________________ Contact Number ___________________________ Parent Information Only: Are you a member of Delta Sigma Theta Sorority, Inc.? ___Yes _____No If yes, please provide chapter name: ______________________________ Is a relative a member? _____Yes _____No If yes, specify the relationship ________________ If active, please provide chapter name: _____________________________ Candidates T-Shirt Size: Please Circle: Adult or Youth XS S M L XL OTHER__________ Parental Permission and Waiver Form I, ___________________________________, hereby authorize the Hattiesburg (Parent Name) Alumnae Chapter, Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) to photograph or film my child,______________________________, (Child Name) and consent to the use of her likeness in any all publications, educational materials, research, advertising, news media and World Wide Web materials. I understand and agree that such materials, including all negatives, positives, digital images and prints shall become and remain the sole property of the Hattiesburg Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) and I shall have no right or title to such items. I further understand and agree that these materials may be kept on file and used by the Hattiesburg Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) for potential future purposes and further agree to release the Hattiesburg Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) from any and all liability arising from or in connection with the taking, use, publication, or dissemination of such materials. Copies of these photos may be distributed to the parent upon request. I agree not to hold the Dr. Betty Shabazz Delta Academy or its affiliates, specifically the Hattiesburg Alumnae Chapter, or its members or appointees individually responsible and/or liable for an injuries or illnesses that my child may sustain while in attendance at the sessions of the Dr. Betty Shabazz Delta Academy. I also agree not to hold the organizations or field trip sites, or its members or appointees individually, liable for the loss or destruction of my child's property. I understand that my child is responsible for taking her medication at the required intervals and that the Dr. Betty Shabazz Delta Academy assumes no responsibility for administering the medication, including over-the-counter medication, to my child. In the case of an emergency, the Dr. Betty Shabazz Delta Academy has my permission to allow treatment by an emergency medical technician, or nurse, doctor, or health care professional and to allow transportation to a local hospital, unless I notify the Dr. Betty Shabazz Delta Academy officials otherwise in writing. I understand reasonable efforts will be made to supervise my child. I, and my child understand that certain conduct on the part of my child will not be tolerated, such as: unacceptable sexual conduct, unacceptable dress, violent speech or conduct, and the use of controlled substances or alcohol, and that the commission of any of these acts will result in my child's immediate dismissal from the program. I understand that in the event that one of these acts occurs, the Dr. Betty Shabazz Delta Academy will contact via telephone at the number listed for the parent or the emergency contact person. I agree that when I or the emergency contact person is called, I or the emergency contact person will immediately come and pick my child up from the session or healthy facility. PARENT/LEGAL GUARDIAN VERIFICATION FORM By my signature, I hereby verify that the above information is current and accurate. I agree to allow my child to participate in the Dr. Betty Shabazz Delta Academy Program. This includes field trips and supporting my child’s regular attendance and participation. Participant Signature: ______________________________________Date:_______________ Parent Signature:__________________________________________Date:________________ **Remember: Completion of this application and attendance does not guarantee membership. All packets will be thoroughly reviewed. Limited slots are available. Thank you for your interest in Dr. Betty Shabazz Delta Academy Program. DR. BETTY SHABAZZ DELTA ACEDEMY PROGRAM Student Performance Review This form is to be completed by a school official such as a teacher, counselor, and/or principal STUDENT INFORMATION Name Subject School Date Grade Teacher Review Period to RATINGS 1 = Poor Student Conduct Comments Student Work Performance Comments Attendance/Punctuality Comments Initiative Comments Communication/Listening Skills Comments Dependability Comments Overall Rating (average the rating numbers above) EVALUATION ADDITIONAL COMMENTS GOALS (as agreed upon by student and teacher) 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent STUDENT INFORMATION Name Subject School Date Grade Teacher Review Period to VERIFICATION OF REVIEW By signing this form, you confirm that you have discussed this review in detail with your teacher. Signing this form does not necessarily indicate that you agree with this evaluation. Student Signature Date Teacher Signature Date