Delta Sigma Theta Sorority GEMS Application
The Dr. Jeanne Noble Delta G.E.M.S is a free program that assist young girls, ages 14-18, to prepare for full participation as leaders in the 21st Century. 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. 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 Email
example@example.com
Applicant's Cell
Please enter a valid phone number.
Format: (000) 000-0000.
Current School, Grade Level, and GPA
Birthdate
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shirt Size
Please Select
Small
Medium
Large
X Large
2X Large
List any honors/awards/achievements and extra-curricular activities.
Please list any special talents/hobbies.
Please list church and community related activities.
What is your strongest academic subject?
What is your weakest academic subject?
Please list your top college/university choice(s) and major/minor.
What is your military branch choice, if applicable?
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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 headaches/fever/cramps, can your child be given Acetaminophen (e.g., Tylenol), Ibuprofen (e.g., Advil, Motrin, Naproxen (Aleve), Midol, or Excedrin?
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 the name of the 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
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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
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