2024-2025 Educational Development Application
Educational Development Committee
Participant's Name
*
First Name
Last Name
Participant's Date of Birth
*
-
Month
-
Day
Year
Date
What committee program are you applying for?
*
GEMS - high school girls
Academy - middle school girls
EMBODI - middle and high school boys
Parent's/Guardian's Name
*
First Name
Last Name
Parent's/Guardian's Email Address
*
Parent's/Guardian's Home Number
Parent's/Guardian's Mobile Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a Henry County resident?
*
Yes
No
Does student attend school in Henry County?
*
Yes
No
School Name (Select your Middle or High School below):
*
Please Select
Dutchtown Middle School
Eagle's Landing Middle School
Hamton Middle School
Locust Grove Middle School
Luella Middle School
McDonough Middle School
Ola Middle School
Stockbridge Middle School
Union Grove Middle School
Woodland Middle School
Dutchtown High School
Eagle's Landing High School
Hampton High School
Locust Grove High School
Luella High School
McDonough High School
Ola High School
Stockbridge High School
Union Grove High School
Woodland High School
If your school is not listed above, please provide your school here:
If you school was not listed above, please provide your school's address:
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level for 2023 -2024
*
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size
*
Note: Adult Sizes
Does the youth participant need a new Polo shirt?
*
Yes
No
Would you like to order a shirt because you have moved from one HCAC program to another (example: Delta Academy now to GEMS)?
Yes
No
Other
How did you hear about the program?
*
What are you hobbies/extra-curricular activities?
*
Is the applicant a returning participant?
*
Yes
No
Is the participant's parent a member of Delta Sigma Theta?
*
Yes
No
Is this a single parent household?
*
Yes
No
Does the participant receive free or reduced lunch?
*
Yes
No
Has the participant ever been expelled from school?
*
Yes
No
If yes, please provide details of the expulsion.
*
Has the participant ever been arrested?
*
Yes
No
If yes, please provide details of the arrest.
*
Please provide a brief summary of the participant's career goals.
*
0/100
Please provide a list of the participant's scholastic achievements/awards (Honor/AP Classes).
0/100
How did you hear about the program?
Participant's Signature
*
Parent's/Guardian's Signature
*
Submit
Should be Empty: