Stone Mountain- Lithonia Alumnae Chapter Youth Initiatives Application

Dear Parent/ Guardian:

The Stone Mountain-Lithonia Alumnae Chapter of Delta Sigma Theta Sorority, Inc. Educational Development Committee would like to extend an invitation to your son and/or daughter to apply for our 2022-2023 youth initiatives programming.

Delta Academy (for middle school young ladies)
Delta GEMS (for high school young ladies)
E.M.B.O.D.I (for middle and high school young men)
College Tour ( for young ladies and young men who are sophomores, juniors & seniors in high school).

If you would like for your daughter and/or son to be a part of one of our extraordinary programs, please fill out the appropriate form and make note of the confirmation screen denoting receipt of your submission. Applications must be completed with all requested information and all signatures in order to be considered.

Space is limited and slots are filled on a first come, first serve basis so do not delay expressing your interest.

For planning purposes, the manadatory/ virtual risk management parent meeting will be held September 20th at 7pm. It is imperative that you use the same email address on your application that you use to register for the virtual parent meeting. Here is the link to register.

Register in advance for this meeting:

https://us02web.zoom.us/meeting/register/tZMrceyopjkvHNR-HncqkXAm-p6QqBUiGMQh

We will be in person this year but are poised to pivot to virtual should circumstances deem necessary. We will follow all recommended protocols from the CDC and the sorority's National Headquarters regarding Covid-19, variants of Covid-19 and all infectious diseases. Masks are required at every in person meeting.

The 3 pronged risk management process implemented last year continues to be in place. Please continue to look for the email with the parent packet that is to be filled out and returned during the in person Welcome/ Kick Off meeting, September 10th at 10am, location is TBD.

We look forward to hearing from you! Have a great start to the school year!

Sincerely,

Ms. Jai Muhammad

Chair, Educational Development, SM- LAC, DST Inc.

Program of Interest (Please fill out an application for each of your scholars)

Delta Academy DekalbDelta GEMS DekalbE.M.B.O.D.I.Delta Academy RockdaleDelta GEMS RockdaleCollege Tour (Meets on Sundays) (Please click here if you’re interested in the College Tour program. Another application specific to the tour will be emailed to you)

Returning Scholar from year 2021-2022

YesNo

Scholar's Name

First NameLast Name

Age

Grade (2022-2023 School Year):

Choose a T-Shirt Size

Address (Scholar must reside in the Stone Mountain, Lithonia, Centerville, Loganville, Snellville or Rockdale County areas)

City

Zip Code

Scholar's Cell Phone

Scholar's Email

example@example.com

Name of School (Please give FULL name not abbreviation)

City

County of Residence

Extra Curricular Activities (If Any)

Hobbies or Talents (If Any)

What do you want to gain from participating in either Delta Academy, Delta GEMS, College Tour or E.M.B.O.D.I. Programming?

About what new subject would you like to learn?

Name

First NameLast Name

Address

City

State

Home Phone

Cell Phone

Email address (Please use the same email address here as you will use or you used to register for the mandatory/ virtual parent meeting)

example@example.com

Name

First NameLast Name

Address

City

State

Home Phone

Cell Phone

Email address

example@example.com

Emergency Contact (if parent/guardian is not available)

Name

First NameLast Name

Address

City

State

Home Phone

Cell Phone

Email address

example@example.com

Relationship To Participant

I First Name Last Name , under penalty of perjury, do hereby affirm to the Stone Mountain-Lithonia Chapter of Delta Sigma Theta Sorority, Incorporated that I authorize the participation of , First Name Last Namein the youth initiative program, and that I have the legal authority to provide my consent and authorization for such participation. I understand that transportation to and from all activities is the sole responsibility of the parent(s)/guardian(s). Should my scholar have discipline issues that arise, I agree to pick them up from the program location immediately. I will disclose any previous/ current discipline issues/reports and withdraw my scholar from the program. I also waive, release, and discharge all claims for personal and property damages arising out of my child's participation. I also understand that sessions may be recorded/ video taped and/or photographed and portions of the materials may be used for promotional materials. I further understand and agree to all Covid-19, Covid-19 variants and all infectious disease recommendations and restrictions. I will ensure my participant wears a mask at all times, washes their hands often and will stay home if she or he is feeling ill.

Please select a response

I DO give permission for my child to be recorded/ video taped or photographed

(Parent/Guardian signature)

Date

PARENT/GUARDIAN INFORMATION FORM

Parent/Guardian #2