Delta Sigma Theta Sorority, Inc.

Delta Sigma Theta Sorority, Inc.
North Broward County Alumnae Chapter Scholarship Application

Application Deadline: March 13, 2022
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ALL MATERIALS SUBMITTED ARE THE PROPERTY OF THE SORORITY
Name
** EMAIL ADDRESS REQUIRED
*Email
example@example.com
Address

Address

Street Address Line 2

City, State ZIPState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Father's Name
Address (if other than above)
Occupation
Employed By
Mother's Name
Address (if other than above)
Employed By
Occupation
Number in Family
Does your family rent or own?
Do you receive any public assistance (i.e. food stamps, Medicaid, TANF, cash assistance)?
Yes
No
Please provide a copy of you FASA Summary Report page. Application is considered incomplete if not provided.
File Upload

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PART II: SCHOLASTIC INFORMATION
High School
Cumulative Grade Point Average
ACT or SAT Score
Class Rank
Guidance Counselor
PART III: EXTRACURRICULAR ACTIVITIES (school, community, etc)
OFFICES HELD/HONORS RECEIVED (Please notate grade year that honor was received)
1.
2.
3.
LIST ANY DELTA ACTIVITIES (school, community, etc)
LIST CURRENT AND PREVIOUS EMPLOYERS
1.
2.
Are you currently in a High School ROTC program?
Yes
No
Do you plan to participate in a Collegiate ROTC program
Yes
No?
If so which branch of military?
Yes
No
Do you plan to attend a vocational school or program?
If so, which vocational school/program do you plan to attend?
Please write a brief essay about your future educational goals and how this scholarship will assist you in achieving these goals.
Note: Incomplete applications will not be considered.

1.Wallet Size Photo. Original 5 x 7 - No watermarks or wording throughout picture request.

2.One letter of recommendation with an original pen/ink signature.

3. Transcript OR upload the "Graduation Information" by signing in to bcps.browardschools.com/virtua counselor Click on student, enter your student # (06 ), enter password student's birthday (MM/DD/YYYY) press submit. Download and attach.

4. Copy of FASA Summary Report

All information above is correct and true.
Describe any special interests or hobbies that you have
File Upload

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Applicant's Signature Contact Number Date
Contact Number
*Applicant's Signature Contact Number

*BOTH SIGNATURES REQUIRED TO BE ACCEPTED*

Application must be received by March 13, 2022
Delta Sigma Theta Sorority, Incorporated Risk Management

PHOTOGRAPH, MEDIA AND VIDEO AUTHORIZATION RELEASE FORM

("Parent/Guardian"), as parent(s) or legal,give permission for North Broward County 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 May Week/ Scholarship Youth 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 May Week/ Scholarship 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 authorized legally to give this consent, and do hereby give my/our consent without reservation to the foregoing on behalf of my/our child.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Name
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Name
Original 5 x 7 - No watermarks or wording requested
Should be Empty:

Delta Sigma Theta Sorority, Inc.

** EMAIL ADDRESS REQUIRED

PART II: SCHOLASTIC INFORMATION

OFFICES HELD/HONORS RECEIVED (Please notate grade year that honor was received)

LIST CURRENT AND PREVIOUS EMPLOYERS