MPBAC Youth Program Application

Melbourne-Palm Bay Alumnae Chapter

Delta Sigma Theta Sorority, Inc.
Youth Programs Application

Revised 2021
Please check the box next to the program for which you are applying: *

Connecting Children with Reading (CCWR) Dr. Betty Shabazz Delta Academy Dr. Jeanne Noble Delta GEMS E.M.B.O.D.I.
Student Name *

First Name Last Name
Age *
Date of Birth *
Gender *
Street Address *
City *
State *
Zip Code *
HomePhone
Cell Phone
Email Address *
example@example.com
School Name *
Grade/Class Level *
GPA
Emergency Contact Information
Name *
Relationship to you *
Street Address *
City *
State *
Zip Code *
Home Phone
Cell phone
Work Phone
Email address *
example@example.com

EXTRA CURRICULAR ACTIVITIES
Please list all other activities that you are involved in during the school year including employment, volunteer work, hobbies, sports or other tutoring/educational programs.
Applicant Name (printed) *
Applicant Signature *

Clear
Parent/Guardian Name (printed) *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
For additional information, please contact:

Ms. Andrea Scott (321) 236-3406

Email: youth@melbournedeltas.org

or

Melbourne/Palm Bay Alumnae Chapter

Delta Sigma Theta Sorority, Inc.

ATTN: Youth Programs

P.O. Box 2885

Melbourne, FL 32902
Questions
Ms. Andrea Scott (321) 236-3406

Email: youth@melbournedeltas.org

PARENTAL/GUARDIAN AFFIRMATION
I, *
Name
hereby give my permission to the Chapter of Delta Sigma Theta Sorority, Incorporated
Chapter Name
for *
Child's Name
to participate in the youth initiative (including planned activities),
Program Name
and I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation. *
Printed Name
Signature *

Clear
Relationship to child: *
Date *

Month Day Year
Date
WAIVER AND RELEASE
I, *
, Parent/Guardian, on behalf of
*
Child name
(“Participant Minor Child”) do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Incorporated (“DST”), its officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, and assigns (collectively “Releases”), 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 Youth Initiative.
Program Name
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 Releases, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of any Releases. 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.
Signature *

Clear
Date *

Month Day Year
Date

PHOTOGRAPH, MEDIA, AND VIDEO AUTHORIZATION RELEASE FORM
I/We, *
Parent Name
as parent(s) or legal guardian(s) of *
Child'sName
give permission for *
Chapter Name
Melbourne-Palm Bay 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 during participation in the
*
Program Name
Initiative Program activities, without payment or any consideration and without notifying me in advance. I/We also give permission for the Chapter to highlight my child’s achievements and activities in efforts to promote the youth initiative program through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media 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
Program Name
Youth Initiative Program 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 *
Child's Name
authorized legally to give this consent, and do hereby give my/our consent without reservation to the foregoing on behalf of my/our child.
Signature *

Clear
Print Name *
Date *

Month Day Year
Date
Signature

Clear
Print Name
Date

Month Day Year
Date

YOUTH CODE OF CONDUCT
1. 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.
2. Res pect 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.
3. Return supplies to their proper place after using them.
4. Clean up all work areas properly.
5. Listen carefully to directions and when someone else is talking.
6. Respect designated quiet areas, such as homework/reading area.
7. Stay within the program’s designated areas within the building.
8. Cooperate and participate in organized activities.
9. Assume full responsibility for all personal belongings. Please lea ve valuables at home.
10. Do not bring any weapons, cigarettes/drugs, alcohol, or anything illegal to any activity at any time.
Sanctions for Violating Code of Conduct
Bad Language/Abusive Teasing and Related Acts:
1st Time: Verbal warning, parent or guardian notified from this point forward

2nd Time: Loss of privileges

3rd Time: 1-week suspension from program Next occurrence youth is removed from the program.

Next occurrence youth is removed from the program
Physical Violence and Other Misconduct:
1st Time: Removal from situation, loss of privileges, guardian notified from this point forward

Next occurrence youth is removed from the program.
Illegal Substances or Dangerous Weapons
set 1Time: Youth is removed from the program. If a youth is in possession of an illegal substance or dangerous weapon, the police will be notified as well.

(Continued on next page)
1 Cyber-bullying is defined in Appendix C4, which sets out the Internet Use Policy.

© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

(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.
Signature *

Clear
Full Name *
Date *

Month Day Year
Date
(Parent)
I have read and understand the Code of Conduct and sanctions for violating the Code of Conduct. I understand that my child’s compliance with the Code of Conduct is a condition of her/his participation in the
Program Name
program. I agree that the sanctions for violating the Code of Conduct are reasonable and will help my child comply.
Signature *

Clear
Print Name *
Date *

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

YOUTH PICK-UP AUTHORIZATION FORM
I authorize the persons listed below to pick-up my child from the
Program Name
youth initiatives program. 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
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 Melbourne-Palm Bay Alumnae Chapter to release my child to the persons listed above. I also agree to notify the Chapter in writing of any changes in the above list of authorized persons.
Mother/Guardian Signature

Clear
Date

Month Day Year
Date
Father/Guardian Signature

Clear
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

PARENT 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 specified 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 transportation received, I, for myself, my child, my executors, and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Melbourne-Palm Bay Alumnae Chapter from any clain 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 agree to be legally bound by its terms.
Signature

Clear
Print Name
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORT YOUTH
ALL TEENAGE DRIVERS MUST HAVE A NON-PROVISIONAL DRIVER’S LICENSE
Name of Child
Event
Location
Student 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 specified location on the date indicated. I understand 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 a teenage driver 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 transportation received/provided, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Melbourne-Palm Bay 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 agree to be legally bound by its terms.
Signature

Clear
Print Name
Date

Month Day Year
Date
Parent/Guardian of Teenage Driver Signature
Print Name
Date

Month Day Year
Date

OFF-SITE PERMISSION
I/We, (“Parent/Guardian”), as parent(s) or legal
of
Child Name
(“Child”), give permission for my/our Child to participate in the
Program Name
Youth “Initiatives”) activities taking place off site. 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, except 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, judgments, 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.
Signature

Clear
Print Name
Date

Month Day Year
Date
Signature

Clear
Print Name
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

MEDICAL INFORMATION AND TREATMENT AUTHORIZATION PACKET
Today's Date

Month Day Year
Date
Youth Name
Date of Birth

Month Day Year
Date
Age
Address
City/State/Zip Code
Parent/Guardian Home Phone
Cell Phone
Please enter a valid phone number.
E-mail Address
example@example.com
Minor’s Gender
Height
Weight
HEALTH INFORMATION
Below please check any current health condition that may require attention during the Program day. Also,

complete and submit the Medication Authorization Form if your child has health conditions that require medication during the Program day.

Asthma Inhaler required at Program:
Asthma Inhaler required at Program?

Yes No
Hearing Problems

Glasses Contacts Hearing Aid(s)
Other
Allergies/Sensitivities (be specific)
Foods
Medicines
Bee sting or insect bite
Other
List all medications and dosages your child receives on a continual basis:

© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

Other (please list)
Does child have any significant health history, conditions, communicable illness, or restrictions that may affect child's participation in the
Name os Program
If yes, please provide detailed explanation
If yes, please provide detailed explanation
Does child have any significant food/medication/environmental allergies that may require emergency medical care at the Youth initiatives program?
Name of Program
(Check One)

None Yes
If yes, please provide detailed explanation
Specify any other serious or severe illnesses or accidents
Does child take prescribed medications? Name the medications
Frequency Taken
(For any medications or treatment required during the youth initiatives program, a Medication Authorization Form should be completed and submitted with this form
Name of Program
Does child take any over the counter medications frequently?
Yes No
Name of the medications
Frequency Taken
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

NON-PRESCRIPTION MEDICATION PERMIT
PLEASE CHECK those medications you give permission for your child to receive (generic equivalent may be used I/We understand that medications will be administered with discretion by an authorized Program employee and in accordance with established protocols developed by the Program.

The following nonprescription medications may be available to your child:
including Junior Strength, Ibuprofen e.g., Advil, including Children’s liquid, Motrin,

For headaches/fever/muscle aches/pain/cramps: Acetaminophen e.g., Tylenol, including Junior Strength, Ibuprofen e.g., Advil, including Children’s liquid, Motrin), Naproxen (Aleve), Midol & Excedrin For bites/allergic rashes: Anti-itching lotion e.g., Calamine or Hydrocortisone cream 1%, Benadryl liquid or capsules. For nasal congestion/sinus pressure: Decongestant For sore throat: Throat lozenges (e.g., Capitol lozenges) For coughs: Cough drops/lozenges or cough suppressant. For upset stomach: Antacid liquid or chewable tablets (e.g., Mylanta) For sun protection: Sunscreen lotion SPF 30.
I DO NOT WANT ANY MEDICATIONS GIVEN TO MY CHILD.
Signature

Clear
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

PHYSICIAN & INSURANCE INFORMATION
Name of Child’s Physician
Phone
Health Insurance Company
Phone
Policy Number
Group Number
Insurance Company Address
City/State/Zip Code
Name of Policy Holder
Name of Policy Holder’s Employer
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

EMERGENCY CONTACT INFORMATION
Parent/Guardian #1

Name
Name
Relationship
Street Address
City
State
Zip Code
HomePhone
Work Phone
Cell Phone
Email address
example@example.com
Parent/Guardian #2
Name
Relationship
Street Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-mail address
example@example.com
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 to Student
Home Phone
Work Phone
Cell Phone
Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
If 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 all expenses incurred and authorize the medical facility at which treatment is rendered to release all necessary information to my/our insurance company.
Signature

Clear
Date

Month Day Year
Date
Signature

Clear
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

MEDICATION AUTHORIZATION FORM
(To be filled out by the physician dispensing the medication)
Name of Minor
Birthdate

Month Day Year
Date
Medication
Dosage
Time of administration
Reason for medication
Route of administration
Possible side effects and significant information
Possible side effects and significant information
Signature

Clear
Date

Month Day Year
Date
Physician’s telephone number
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

PARENTAL PERMISSION FORM ADMINISTRATION OF PRESCRIPTION MEDICATION
I/We hereby give permission for
child's name
to take
medication name
at the
Program Name
youth initiatives program as ordered by his/her physician identified above
I/We understand that it is my/our Child’s responsibility to report to
Program chair
at the appropriate time for the Administration of the medication.

I/We further understand that it is my/our responsibility to furnish this medication and any authorized refills. I/We further understand that Delta Sigma Theta Sorority, Incorporated (“DST”), its officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, assigns the
youth initiatives program, its agents, and/or any
Program Name
employee who administers any drug to my/our child, in accordance with written instructions from the prescriber, shall not be liable for damages as a result of an adverse drug reaction or any other injury suffered by my/our child due to the administration or failure to provide the drug.
The
youth initiatives program reserves the right to refrain from
administering medication if in the judgment of the
program, or other authorized Program officer, agent, or employee the circumstances do not warrant medication administration.
I/We understand that the medication must be brought to the
Program Name
initiatives program by me/us in the original appropriately labeled container.

If I/we cannot bring the medication to the
youth initiatives program, I/we will call the
Program Name
youth initiatives program to inform them that my/our child will be bringing it, indicating the amount of medication in the container.
Signature

Clear
Date

Month Day Year
Date
© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.

MEDICATION ADMINISTRATION PROCEDURES
Prescription Medication
1. We require the Medication Authorization Form to be completed by the prescribing physician and the parent. For each prescription medication ordered, the physician must give the following information: (1)the student’s name, (2) the medication, (3) the dosage, (4) the time of administration, (5) the reason for administration, (6) the route of administration, (7) the possible side effects, and (8) any other significant information. The form must then be signed and dated by the prescribing physician. Signed parental consent is also required for each medication. This consent releases Delta Sigma Theta Sorority, Incorporated, the
Program Name
youth initiatives program, and their officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, and assigns from liability if the medication causes adverse reactions. The Medication Authorization Form is updated annually.

2. The original prescription container must accompany all medication to be given at the youth initiatives program.
Program Name
Medications should be brought to the
Program Name
youth initiatives program by the parent or responsible adult and taken to
Program Chair
The original prescription container should be labeled with the following information: name of student, name of medication, dosage of medication to be given, frequency of administration, route of administration, name of physician ordering medication, date of prescription, and expiration date.

3. If possible, the parent should provide
days’ worth of the medication if it is to be given every day. It is the parent’s responsibility to provide adequate refills on a timely basis.

4. All medication is always kept in a locked cabinet or locked container. If not retrieved by a parent or responsible adult, all medication will be destroyed one week after the expiration date or at the end of the term for the
youth initiatives program.
Program Name
5. A record will be maintained every time a medication is given. The record includes the student’s name, date, time of administration, and dosage.
Over-the-Counter Medication
1.Written parental/guardian consent for the administration of over-the-counter medication is obtained through the emergency forms.

2. A record will be maintained every time a medication is given. The record includes the student’s name, date, time of administration, and dosage.
1 A copy of the Medical Treatment Authorization is attached hereto as Appendix B8.

© 2020 Delta Sigma Theta Sorority, Inc. This content is protected under US Copyright (17 U.S.C. §§ 201 et al and other federal law and shall not be published, reproduced, displayed or otherwise utilized by any party whatsoever without the express written consent of Delta Sigma Theta Sorority, Inc. Violation of Delta’s intellectual property rights will be prosecuted to the full extent of the law.
Should be Empty:

Youth Programs Application

Emergency Contact Information

EXTRA CURRICULAR ACTIVITIES

Questions

PARENTAL/GUARDIAN AFFIRMATION

WAIVER AND RELEASE

PHOTOGRAPH, MEDIA, AND VIDEO AUTHORIZATION RELEASE FORM

YOUTH CODE OF CONDUCT

Sanctions for Violating Code of Conduct

Bad Language/Abusive Teasing and Related Acts:

Physical Violence and Other Misconduct:

Illegal Substances or Dangerous Weapons

(Student Participant)

(Parent)

YOUTH PICK-UP AUTHORIZATION FORM

PARENT WAIVER AND PERMISSION TO TRANSPORT YOUTH

PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORT YOUTH

ALL TEENAGE DRIVERS MUST HAVE A NON-PROVISIONAL DRIVER’S LICENSE

OFF-SITE PERMISSION

MEDICAL INFORMATION AND TREATMENT AUTHORIZATION PACKET

HEALTH INFORMATION

Health History:

Health and Developmental History:

NON-PRESCRIPTION MEDICATION PERMIT

PHYSICIAN & INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

Parent/Guardian #1

Parent/Guardian #2

MEDICATION AUTHORIZATION FORM

PARENTAL PERMISSION FORM ADMINISTRATION OF PRESCRIPTION MEDICATION

MEDICATION ADMINISTRATION PROCEDURES

Prescription Medication

Over-the-Counter Medication