Delta GEMS Application 2025-2026

Leesburg Alumnae Chapter of

Delta Sigma Theta Sorority, Inc.
Growing & Empowering Myself Successfully (G.E.M.S)

2025-2026

Contact Information & Application Packet

Ms. Carole Spikes, GEMS Chairperson

Contact Info: LeesburgDeltaGems@gmail.com

Mandatory Parent/Child Meeting

TBD- (To Be Determined)

Location: TBD
The Dr. Jeanne L. Noble Delta G.E.M.S Program was established in 2004 to provide a vehicle of change for young ladies between the ages of 14 and 18 to enhance their abilities and increase their self-worth, in order to achieve academic excellence. The program’s mission is to provide young ladies with an opportunity to enhance their self-esteem, academic achievement, leadership skills, and cultural awareness. Through structured activities those who participate will evolve emotionally, socially, and intellectually and be prepared to take an active role in their successs as they face the challenges of life.
THIS PACKET MUST BE RECEIVED ON OR BEFORE October 17 2025

Delta Sigma Theta Sorority, Inc. - Leesburg Alumnae Chapter

Delta G.E.M.S. Application

The following application packet must be completed, signed/initialed where applicable. Failure to submit a COMPLETE packet may exclude the applicant from consideration.
New ApplicantReturning Applicant
Prospective GEM Participant Information:
Name*

First NameLast Name
Age*
Birth Date*

MonthDayYear
School Grade for 2025-26*
Cell Phone Number*
Please enter a valid phone number.
Name of High School *
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adult Shirt Size:*

MLXLXXLXXXL
Parent or Guardian Name:*

First NameLast Name
Parent/Guardian Primary Phone Number*
Please enter a valid phone number.
Parent/Guardian Primary Email*
example@example.com
Is your child available to meet on Sundays @ 2pm?*

YesNo
Favorite School Subjects?*
What community service activities or cultural events are you interested in?*
THIS PACKET MUST BE COMPLETED, SIGNED AND RETURNED ON OR BEFORE October 17, 2025

Delta Sigma Theta Sorority, Inc. - Leesburg Alumnae Chapter Delta G.E.M.S. Application
Extra-Curricular Activities:*
What are your Hobbies:*
What talents do you have? What do you like to do?*
Do you have an immediate family member who is a member of Delta Sigma Theta Sorority, Inc. ?*

YesNo
If, yes please provide the name of the person. *
What new subject(s) would you like to learn about?*

CODE OF CONDUCT CONTRACT
Sorority Responsibilities:
*When applicable.
- We will create a welcoming and positive learning environment for the GEMS.
- We will ensure that GEMS are supervised at all times. *
- We will not leave the meeting facility until the last GEM has been picked up. *
- We will conduct meetings in a business-like manner.
- We will begin and end meetings on time.
Parent/Guardian Responsibilities:
- I will make sure that my child strives for 100 percent attendance and will contact the GEMS Campus representative, if my child will be absent at least 24 hours in advance or by any designated deadline.
- I will respond to email correspondence in a timely manner when received.
- I will do my best to participate in activities where parental support is requested.
- I will support the purpose of the program by encouraging my daughter to do her very best in all activities.
- I will ensure that my daughter is dropped off and picked up on time for each activity. (When applicable.)
GEMS Participant Responsibilities:
Participant's Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
GEMS Volunteer Name

First NameLast Name

Delta Sigma Theta Sorority, Inc. - Leesburg Alumnae Chapter Delta G.E.M.S. Application
YOUTH INITIATIVE VIRTUAL MEETING/EVENT

Participation Agreement
as parents of *

First NameLast Name
I give permission for Delta Sigma Theta Sorority, Inc. (“the Sorority”) and the Leesburg Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”, together with the Sorority, “Delta”) to host and facilitate closed virtual meetings/events using Zoom (“the Virtual Meeting Platform”), that my/our child will attend during participation in GEMS Youth Initiative Program activities, without payment or any consideration and without notifying me in advance and hereby acknowledge, understand, and agree to the terms enumerated below, including the terms set forth on any Schedules attached hereto and incorporated by reference (the "Participation Agreement"

I/We also understand that the Virtual Meeting Platform may collect information about its users and has its own privacy terms and conditions to which users must adhere. I/We will be responsible for reviewing the virtual meeting platform’s privacy terms and conditions before registering for virtual meetings/events. I/We also understand that my/our child will need the following to participate in a virtual meeting platform.
- A computer, mobile, or tablet device with access to the Internet
- A quiet space in which participants can participate in the virtual meeting/event under the supervision of an adult
- Registration for the virtual meeting/event platform and provide some customer data (including but not limited to an email address, first and last name, etc
I/We also understand, acknowledge and agree to indemnify, defend, protect and hold harmless the Chapter and any of its officers and members; and the Sorority and any of its officers; National Executive Board; employees; members; representatives; agents; and assigns from and against any and all liability, whether in law or in equity, should there a breach of security of the Virtual Meeting Platform and any subsequent injury, malice, or harm that might occur as a result, and waive and release any and all rights with respect to the same.

I/We hereby hold harmless and release and forever discharge the Chapter and any of its officers and members; and the Sorority; 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 Virtual Meeting Platform as a venue for meetings or events. 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 and content of the virtual meeting/event, 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 behalf of my/our child.

I/We have fully read and understand the Code of Conduct (attached hereto as Schedule 1 I understand that my child’s compliance with the Code of Conduct is a condition of her/his participation in the program. I further acknowledge, understand, and agree that the sanctions for violating the Code of Conduct are reasonable and should my child be non-complaint, they will be subject to the prescribed disciplinary action.

I/We also give permission for the Chapter and the Sorority to highlight my/our child’s achievements and activities in efforts to promote the youth initiative program through the Virtual Meeting Platform that will include the use of still photographs, moving images or live images, and chats including, if applicable any sound recordings accompanying the images (“Images”) taken of my/our child or provided by my/our child during participation in the Delta G.E.M.S. Youth Initiative Program in accordance with the terms set forth in the Media and Publication Releases (attached hereto as Schedule 2)
Participant Acknowledgement (Student Participant)
With my parent/guardian, I have fully read and understand the Participation Agreement. I acknowledge that should I fail to abide to the Code of Conduct that my actions will be subject disciplinary action as defined. I hereby acknowledge, understand, and agree to comply with the terms set forth in the Participation Agreement.
Participant Signature*

Clear
Name*

First NameLast Name
Parent/Guardian Acknowledgment
I have fully read and understand the Participation Agreement. I also understand that my child’s compliance with the Code of Conduct is a condition of her/his participation in the program. I hereby acknowledge, understand, and agree to comply with the terms set forth in the Participation Agreement.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear

I/We, as parents/guardian*

First NameLast Name
Delta Sigma Theta Sorority, Inc. - Leesburg Alumnae Chapter Delta G.E.M.S. Application
SCHEDULE 1
YOUTH INITIATIVE VIRTUAL MEETING AND PUBLICITY

CODE OF CONDUCT
The Youth Participant Virtual Meeting and Publicity Code of Conduct serves as codified guidance for youth participation in Delta’s Youth Initiative Programs, namely those of a virtual nature. Your signature on the Participation agreement indicates your complete understanding and agreement to comply with this Code of

Failure to comply with this Code of Conduct may result in loss of privileges and/or removal from Delta’s Virtual Youth Initiative Programs. As a youth participant in Delta’s Virtual Youth Initiative Programs

you are expected to: Refrain from use of any profane, foul, hurtful, obscene or vulgar language in any virtual chatroom and during the virtual meetings and events; Refrain from engaging in any violence, cyber-bullying, or other aggressive behaviors that may threaten the welfare of other participants; Refrain from any disruptive behavior that may disrupt the virtual meetings and events; Be properly groomed and dressed for all virtual youth initiative meetings and events, refrain from wearing articles of clothing that displays profane or obscene language and/or images; Keep your camera on at all times during all virtual youth initiative meetings and events;

Provide a noise-free environment while participating in any and all virtual youth initiative meetings

Refrain from taking, presenting, and posting any photographs, screen shots, video recordings, and/or screen recordings of any virtual youth initiative meetings or any confidential information

disseminated during any virtual youth initiative meetings; Refrain from taking, presenting, and posting any and all inappropriate content including photographs, screen shots, video recordings, and/or screen recordings of any other youth participants of Delta’s youth initiative programs;

Contact the leader of your youth initiative program if you have any questions or need clarification regarding the Code of conduct.
SANCTIONS FOR VIOLATING CODE OF CONDUCT
Bad Language/Abusive Teasing and Related Acts:
1. 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
2. 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.
3. Illegal Substances or Dangerous Weapons – 1st Time: 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.
Student Name*

First NameLast Name
Student Signature*

Clear

SCHEDULE 2

MEDIA & PUBLICATION RELEASE
In accordance with the terms of the Participation Agreement, Delta Sigma Theta Sorority, Inc. (“Delta”) will be filming, recording and photographing this event for use in Delta promotional videos, photography, advertisements, social media platforms, web pages, and other future Delta events, as the case may be, (the “Production”In addition, Delta may use and publicize the name, image, likeness, and any other personal characteristics or other information provided by or related to the Participant that is derived from the filming, recording and photographing of this event for use in Delta videos, photography, articles, as well as any advertising and promotional materials on mediums that may include on-demand, streaming, or other web services, social media platforms, and print news and information outlets, and any other the case may be (the “Publication”

As specified within the Agreement therein, participant and participant’s parent/guardian (participant and participant’s parent/guardian together, “Participant”), via continued participation in and by continuing to remain logged into this event, hereby:

(i) acknowledges that Participant may be photographed, filmed or otherwise recorded while on the premises of the event,

(ii)grants Delta, its successors, assigns and licensees (“Authorized Persons”) irrevocable consent to include Participant’s name, likeness, photographic image, mannerisms and voice or other recording (“Media”) in any Publication or for any purpose whatsoever in any and all mediums now known or hereafter devised throughout the universe in perpetuity without compensation and/or credit,

(iii)acknowledges no right to review or approve Materials before they are used by Delta, and that Delta has no liability to me for any editing or alteration of the Materials or for any distortion or other effects resulting from Delta’s editing, alteration, or use of the Materials, or Delta’s presentation of me, should Delta choose create or use the Materials or to exercise any rights given by this Agreement,

(iv)acknowledges that Delta is the exclusive owner of all display, publication, and ownership rights, including copyright, trademarks, and any other intellectual property, from Media and Materials arising in any jurisdiction throughout the universe in perpetuity, including all registration, renewal, and reversion rights, and the right to sue to enforce such intellectual property against infringers,

(v)acknowledges that Delta holds and shall forever hold all display, publication and ownership rights, licenses and privileges to any and all Media, whether in law or in equity, which may be asserted, ascertained, registered or in any way utilized with respect thereto,

(vi)waives all legal and equitable rights against Delta and any authorized persons relating to all liabilities, claims, demands, actions, suits, damages, and expenses, including but not limited to claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory, now known or hereafter known in any jurisdiction throughout the world, arising directly or indirectly from Authorized Persons ' exercise of their rights under this Release and whether resulting in whole or in part from the negligence of the Sorority, the Chapter, or any other persons, and

(vii)agree that this Agreement cannot be terminated, rescinded, or modified, in whole or in part.

Participant further agrees to abide by and comply with any and all terms of use and/or additional participation rules as applicable and specified during relevant sections of the program and acknowledges, understands, and agrees that violation of such participation rules shall result in legal recourse and disciplinary action.

PARENTAL CONSENT FORMS

October 2025 - May 2026
Parent/Guardian's Name *

First NameLast Name
Student's Name*

First NameLast Name
Relationship:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone:*
Cell Number*
Please enter a valid phone number.
E-Mail Address (home or work)*
example@example.com
How many years has your child been in the program?*
Please list any illnesses, allergies, medications or physical limitations that the G.E.M.S committee members should be aware of.*
What is something new you would like for your daughter to learn from the program this year? *

PARENTAL CONSENT FORMS

October 2025-May 2026
By my signature below, I hereby verify that the above information is accurate. My signature grants permission for my child to participate in the Growing and Empowering Myself Successfully (GEMS) Program, field trips, and activities therein. In giving my permission to participate, I understand that she will take part in scheduled meetings, workshops, cultural, educational and recreational programs. I agree to provide transportation for my child to all scheduled meetings and activities. I also agree to facilitate and support my child’s timely attendance and participation.

I agree not to hold the Leesburg Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or the GEMS Program and its members responsible and/or liable for any injuries or illnesses that my child may sustain while in attendance at the sessions of the GEMS Program. I also agree not to hold the above named organizations, or its members or appointees individually, liable for the loss or destruction of my child's property.
Parent/Guardian Signature *

Clear

Growing & Empowering Myself Successfully (G.E.M.S)

2025-2026 Information & Application Packet
Should be Empty:

THIS PACKET MUST BE RECEIVED ON OR BEFORE October 17 2025

Prospective GEM Participant Information:

THIS PACKET MUST BE COMPLETED, SIGNED AND RETURNED ON OR BEFORE October 17, 2025

CODE OF CONDUCT CONTRACT

Sorority Responsibilities:

Parent/Guardian Responsibilities:

GEMS Participant Responsibilities:

YOUTH INITIATIVE VIRTUAL MEETING/EVENT

Participant Acknowledgement (Student Participant)

Parent/Guardian Acknowledgment

SCHEDULE 1

YOUTH INITIATIVE VIRTUAL MEETING AND PUBLICITY

SANCTIONS FOR VIOLATING CODE OF CONDUCT

Bad Language/Abusive Teasing and Related Acts:

SCHEDULE 2

PARENTAL CONSENT FORMS

PARENTAL CONSENT FORMS