Delta Sigma Theta Sorority Academy Application
The Dr. Betty Shabazz Delta Academy is a free program that assists young girls, ages 11-14, to prepare for full participation as leaders in the 21st Century. All girls must be in Middle School to participate. This form is due by Tuesday, October 6, 2026. There will also be a mandatory virtual Risk Management Orientation for parents and program participants on October 11, 2026 at 6:30pm. Please send any questions or requests for additional information to the following email address: deltaacademygems@warnerrobins-dst.org.
Applicant's Name
First Name
Last Name
Address
Applicant's Birthdate
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current School, Grade Level, and GPA
Shirt Size
Please Select
Small
Medium
Large
X Large
2X Large
What are your career goals?
Honors/Awards/Achievements: Please list extra-curricular activities in which you participate.
On a scale of 1 to 10 (10 being the highest), rate your science interest.
Please Select
10
9
8
7
6
5
4
3
2
1
On a scale of 1 to 10 (10 being the highest), rate your technology interest.
Please Select
10
9
8
7
6
5
4
3
2
1
On a scale of 1 to 10 (10 being the highest), rate your math interest.
Please Select
10
9
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5
4
3
2
1
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Participant/Child's Name
Has there been a professional diagnosis of ADD/ADHD?
Yes
No
Can your child be given Sunscreen lotion during outside activities?
Yes
No
Call the parent first to confirm
For bites/allergic rashes, can your child be given Anti-itching lotion (e.g., Calamine, Hydrocortisone cream) or Benadryl?
Yes
No
Call the parent first to confirm
For sore throat, sinus, and upset stomach issues, can your child be given a decongestant, throat lozenge, cough suppressant, or antacid?
Yes
No
Call the parent first to confirm
Do you have asthma? Please indicate is an inhaler is required.
Please list any allergies/sensitivities.
Do you have vision and/or hearing issues? Please indicate if you wear glasses, contacts, hearing aids, etc.
Please provide name of Health Insurance Company
Name and number of child's physician.
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Participant/Child's Name
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Relationship to the Participant
Parent's Name
Parent's Phone Number
Format: (000) 000-0000.
Parent's Email
example@example.com
Upload Applicant's Photo
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Parent/Guardian (electronic signature)
Applicant (electronic signature)
Date Completed
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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