Delta Youth Programs Application

Delta Youth Programs Application

Columbus (OH) Alumnae Chapter
Which Youth Program are you applying?*
Are you returning participant?*
Participant Information
Participant Name*

First NameLast Name
Participant Address*

Street Address

CityState

Zip Code
Participant Date of Birth*

MonthDayYear
Date
Participant Age*
Email
example@example.com
T-Shirt Size*
Are there any activities that would prevent you from fully participating in actives in September - May?*
List the dates you will be unable to attend.
School Information
School Name*
Grade Level for the Fall School Year*
Parent/ Legal Guardian Information
Parent/ Legal Guardian #1 Name*

First NameLast Name
Parent/ Legal Guardian #1 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/ Legal Guardian #1 Cell Phone Number*
Please enter a valid phone number.
Parent/ Legal Guardian #1 Home Phone Number
Please enter a valid phone number.
Relationship to Participant*
Parent/Legal Guardian #1
Parent/ Legal Guardian #1 Email*
example@example.com
Parent/ Legal Guardian #2 Name

First NameLast Name
Parent/ Legal Guardian #2 Address (if the address is the same as Parent/Guardian#1)

Skip if the address is the same as Parent/Guardian #1
Parent/ Legal Guardian #2 Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/ Legal Guardian #2 Cell Phone Number
Please enter a valid phone number.
Parent/ Legal Guardian #2 Home Phone Number
Please enter a valid phone number.
Relationship to Participant
Parent/Legal Guardian #2
Parent/ Legal Guardian #2 Email
example@example.com
Parent/ Legal Guardian Signature: Signature*
Date

MonthDayYear
If you have any questions, please contact the Youth Program subcommittee Co-Chairs.
- Delta G.E.M.S. send email to Columbusohdeltagems@gmail.com
- Delta Academy send email to cacohdeltaacademy@gmail.com
Please also note applications should be submitted by September 13, 2024.(Parent/applicant signature is required where specified). Applications not filled out completed by the specified date will not be considered for acceptance into the Youth Programs for the upcoming year.

RISK MANAGEMENT FORMS
The forms contained herein have been approved by Delta Sigma Theta Sorority,
Incorporated, for use by all Chapters. To minimize risk and legal liability, Chapters
are prohibited from modifying or altering these forms, except for inserting the
name of the Chapter, Youth, Parent/Guardian, or Volunteer.

Revised Version: 9/2023
Parent/ Legal Guardian Forms Checklist

APPENDIX B1 PARENTAL/GUARDIAN AFFIRMATION WAIVER AND RELEASE
I, {parentGuardian13}  ,Parent/Guardian, on behalf of {participantName} (“Participant Minor Child”) (“Participant Minor Child”) do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Incorporated (“Delta”), its officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, and assigns (collectively “Releases”), from any and all claims, demands, and actions of any and every kind directly or indirectly arising out of, or relating in any respect to Participant Minor Child’s participation in the Chapter’s Youth Initiative.

My waiver and release of all claims, demands, actions, and liability shall include, without limitation, any injury, illness, death, property damage or loss to the Participant Minor Child which may be caused by any act, or failure to act, by the Releases, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of any Releases. I understand that, without limitation of
the foregoing, neither Delta, nor the Program, shall be liable and each is hereby released from all claims that may arise from loss or damage to the Participant Minor Child’s personal property.

As the Parent/Guardian, I hereby give my permission for my child to participate in the Chapter’s youth initiative (including planned activities), and I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation.

Signature:    Signature*
Relationship to Participant: {relationshipTo198}
Date:  {date194}

APPENDIX B2 PHOTOGRAPH, MEDIA, AND VIDEO AUTHORIZATION RELEASE FORM
I, {parentGuardian13}, Parent/Guardian, on behalf of {participantName} (“Participant Minor Child”) give permission for the local 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 Youth Initiative Program activities, without payment or any consideration and without notifying me in advance. I 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 understand and agree that these Images will become the property of the Chapter, which shall have complete ownership of the Images. I hereby irrevocably authorize the Chapter to publish or distribute
these Images for the purpose of publicizing the Chapter’s programs, including the 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 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 hereby certify that I am the Parent/Guardian, and I am authorized legally to give this consent, and do hereby give my consent without reservation to the foregoing on behalf of my child.

Signature: Signature*
Date: {date194}

APPENDIX B3 YOUTH CODE OF CONDUCT FOR IN‐PERSON MEETINGS
PARTICIPANT NAME: {participantName}

1. Respect all participants (other youth and adult volunteers) by not using foul, hurtful, or obscene language or engaging in physical violence, bullying (including cyber-bullying), or other aggressive behaviors that threaten the safety of others.
2. Respect the property rights of others. This means do not damage or deface the building or property within the building where Chapter activities are held; do not damage or take the personal property of any other participant or volunteer; and do not use Delta’s name or any symbol or logo (Delta’s intellectual property) on any clothing, books, bags, or other items.
3. Return supplies to their proper place after using them.
4. Clean up all work areas properly.
5. Listen carefully to directions and when someone else is talking.
6. Respect designated quiet areas, such as the homework/reading area.
7. Stay within the program’s designated areas within the building.
8. Cooperate and participate in organized activities.
9. Assume full responsibility for all personal belongings. Please leave valuables at home.
10. Do not bring any weapons, cigarettes/drugs, alcohol, or anything illegal to any activity at any time.

Sanctions for Violating Code of Conduct

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 the program
> Next occurrence, youth is removed from the program.

Physical Violence and Other Misconduct:
1st Time: Removal from the situation, loss of privileges, Guardian notified from this point forward
> Next occurrence, youth is removed from the program.

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.

YOUTH CODE OF CONDUCT FOR IN‐PERSON MEETINGS

PARTICIPANT NAME: {participantName}

(Student Participant)

With my parent or other adult, I have read the Code of Conduct and sanctions for violating the Code. I understand the Code and the sanctions. I will follow the Code of Conduct.

Signature: Signature*
Date:  {date194}
Print Name: {participantName}

(Parent)

I have read and understand the Code of Conduct and sanctions for violating the Code of Conduct. I understand that my child’s compliance with the Code of Conduct is a condition of her/his participation in the Chapter’s youth program. I agree that the sanctions for violating the Code of Conduct are reasonable and will help my child comply.

Signature:   Signature*
Date: {date194}
Print Name: {parentGuardian13}

APPENDIX B4 YOUTH PICK‐UP AUTHORIZATION
I, {parentGuardian13} authorize the persons listed below to pick‐up
{participantName} from the youth initiatives program. For my child’s safety, I understand that all authorized persons on the list below will be asked to show photo
identification before my child is released to them; therefore, I will notify all authorized persons of this requirement so that they will have photo identification with them when they arrive to pick-up my child.
Name*

First NameLast Name
Relationship*
Home Phone
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Home Phone
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Home Phone
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Home Phone
By signing below, I verify that I have read and agree to the Student Pick-Up policies described above and authorize the Chapter to release my child to the persons listed above. I also agree to notify the Chapter in writing of any changes to the above list of authorized persons.

Signature: Signature*
Date: {date194}

APPENDIX B5 PARENT WAIVER AND PERMISSION TO TRANSPORT
Name of Child: {participantName}
Event/ Location:   *
Driver:   *
(Note: If giving permission for driver to transport youth to all activities, please indicate “ALL” for Event/Location)

I, {parentGuardian13}  give permission for my child (“child”) to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver.

I have read, understand, and discussed with my child that:
1) They will be traveling in a vehicle driven by an adult, and they are to wear their safety-belt while traveling.
2) They are expected to respect the vehicles they ride in, and the person they travel with during the trip.
3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions, or acts by riders, other drivers, or objects; and
4) They are to remain in their seats and not be disruptive to the driver of the vehicle.

I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received, I, for myself, my child, my executors, and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Chapter from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand
it, and agree to be legally bound by its terms.

Signature:   Signature*
Date: {date194}

APPENDIX B6a
PARENT WAIVER AND PERMISSION FOR YOUTH TO BE TRANSPORTED BY TEENAGE DRIVER
ALL TEENAGE DRIVERS MUST HAVE A NON‐PROVISIONAL DRIVER’S LICENSE
Is the youth a licensed driver?*
If the youth is NOT a license driver, skip Appendix B6a and Appendix B6b.
Name of Child: {participantName}
Event:
Location:
Teenage Driver:
(Note: If giving permission for driver to transport youth to all activities, please indicate “ALL” for Event/Location)

I give permission for my child (“child”) to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver.

I have read, understand, and discussed with my child that:
1) They will be traveling in a vehicle driven by a teenage driver, and they are to wear their safety-belt while traveling.
2) They are expected to respect the vehicles they ride in, and the person they travel with during the trip.
3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions, or acts by riders, other drivers, or objects; and
4) They are to remain in their seats and not be disruptive to the driver of the vehicle.

I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received/provided, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Chapter from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully
understand it, and agree to be legally bound by its terms.

Participant Parent/Guardian Signature:   Signature
Date: {date194}

Teenage Driver Parent/Guardian Signature:   Signature
Date: {date194}

If the youth is NOT a license driver, skip Appendix B6a and Appendix B6b.
APPENDIX B6b

PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORT YOUTH

ALL TEENAGE DRIVERS MUST HAVE A NON‐PROVISIONAL DRIVER’S LICENSE

Name of Child (being transported): {participantName}
Event:
Location:
Teenage Driver:
(Note: If giving permission for driver to transport youth to all activities, please indicate “ALL” for Event/Location)

I give permission for my child (“child”) to transport the individual identified above in a motor vehicle to the event at the specified location. I understand my child is expected to follow all applicable laws regarding driving a motor vehicle and is expected to follow the directions provided by all motor vehicle laws.

I have read, understand, and discussed with my child that:
1) They will be driving a vehicle with other youth participants, and they are to wear their safety-belt while traveling.
2) They are expected to respect the vehicles they ride in, and the person they travel with during the trip.
3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions, or acts by riders, other drivers, or objects.

I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Chapter from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand
it, and agree to be legally bound by its terms.

Participant Parent/Guardian Signature:   Signature
Date: {date194}

Teenage Driver Parent/Guardian Signature:   Signature
Date: {date194}

APPENDIX B7

OFF‐SITE PERMISSION

I, {parentGuardian13}, as parent or legal guardian give permission for {participantName} to participate in the Chapter’s Youth Initiatives Program’s (the “Initiatives”) activities taking place off site. I understand that transportation to and from these activities will be provided for my Child by the Chapter.

I understand that the field trips are part of the Initiatives and if I choose to not have my Child participate in one or more off‐site activities, I must make other care arrangements for my/our child during the times of that field trip activity.

I assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, except for gross negligence or intentional infliction of harm by the Initiatives, its officers, agents, or employees.

I do hereby agree to release and hold harmless the Initiatives, 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 for any damage, loss, or injury to my/our child or damage to my/our child’s property arising from my/our child’s participation in field trips, other than damage, loss, or
injury that results from gross negligence or intentional infliction of harm by the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns.

Signature: Signature*
Date: {date194}

APPENDIX B8 MEDICAL AND EMERGENCY CONTACT INFORMATION
Minor Name: {participantName}

Address: {participantAddress}

Date of Birth: {participantDate}
Physician Name*
Physician Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physician Phone Number*
Please enter a valid phone number.
Below please check any current health conditions that may require attention during the Program day.

Health Condition*

	YES	NO
Anemia
Asthma Inhaler required?
Attention Deficit Hyperactivity Disorder
Diabetes
EpiPen Injections required?
Food Allergies (specify below)
Hearing Loss
- ASL interpreter required?
- Hearing Assistant required?
Headaches or Migraines
Heart Disease
Mobility Issues (please specify below)
Seizure Disorder (i.e., epilepsy)
Sensitivities (i.e., insect bites) - Be specific below
Vision Problems
- Contact lenses required?
- Eyeglasses required?

Specify Food Allergies:
Specify Mobility Issues:
Sensitivities Be Specific (i.e., insect bites):
Are any other conditions or restrictions required? Please specify.*
Please specify any other conditions or restrictions required
The Parent/Guardian may stay or return to administer any required medications to a youth participant.
EMERGENCY CONTACT
Name of Parent/ Guardian #1 : {parentLegal40}

Address of Parent/ Guardian #1: {parentLegal227}

Cell Phone Number of Parent/Guardian #1: {parentLegal39}

Home Phone Number of Parent/Guardian #1: {parentLegal230}
Name of Parent/ Guardian #2 : {parentLegal38}

Address of Parent/ Guardian #2: {parentLegal228}

Cell Phone Number of Parent/Guardian #2: {parentLegal24}

Home Phone Number of Parent/Guardian #2: {phoneNumber233}
If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.
Name #1*

First NameLast Name
Address #1:*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number #1*
Please enter a valid phone number.
Home Phone Number #1
Please enter a valid phone number.
Name #2

First NameLast Name
Address #2:

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number #2
Please enter a valid phone number.
Home Phone Number #2
Please enter a valid phone number.
If the Program is unable to reach any of the individuals named above promptly by phone, I/we authorize the Program to seek and secure any emergency medical or surgical care for my/our child. I/We will be responsible for all expenses incurred and authorize the medical facility at which treatment is rendered all necessary information to my/our insurance company.

Parent/Guardian Signature #1: Signature*

APPENDIX B9

VIRTUAL MEETING/EVENT PARTICIPANT AGREEMENT

I, {parentGuardian13} (“Parent/Guardian”), as a parent or legal guardian of, {participantName}, give permission for Delta Sigma Theta Sorority, Incorporated (the “Sorority”) and the Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”), to host and facilitate closed virtual meetings/events using Zoom (the “Virtual Meeting Platform”), that my child will attend during participation in the 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 "Participant Agreement").

I 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 will be responsible for reviewing the Virtual Meeting Platform’s privacy terms and conditions before registering for virtual meetings/events.

I also understand that my 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 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 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 hereby certify that I am the Parent/Guardian and is authorized legally to give this consent, and do hereby give my consent without reservation to the foregoing behalf of my child.

I 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-compliant, they will be subject to the prescribed disciplinary action.

I also give permission for the Chapter and the Sorority to highlight my 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 child or provided by my child
during participation in 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 Participant Agreement. I acknowledge that should I fail to abide to the Code of Conduct that my actions will be subject to disciplinary action as defined. I hereby acknowledge, understand, and agree to comply with the terms set forth in the Participant Agreement.

Signature:   Signature*

Print Name: {participantName}

Date:   {date194}

Parent/Guardian Acknowledgment

I have fully read and understand the Participant 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 Participant Agreement.

Signature:   Signature*

Name:  {parentGuardian13}

Date:   {date194}

APPENDIX B9.1, Schedule 1

YOUTH INITIATIVE VIRTUAL MEETING AND PUBLICITY

CODE OF CONDUCT

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

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 the 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.
- Always keep your camera on during all virtual youth initiative meetings and events.
- Provide a noise-free environment while participating in all virtual youth initiative meetings and events.
- 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 all inappropriate content, including photographs, screenshots, 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
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.

APPENDIX B9.2, Schedule 2

MEDIA & PUBLICATION RELEASE

In accordance with the terms of the Participant 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:

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

2) 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,

3) 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,

4) 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,

5) 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,

6) 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

7) 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.

APPENDIX B11

CONFIDENTIALITY POLICY

It is the policy of the local Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to protect the confidentiality of its youth participants and their families. Except as provided below, the Chapter will only share information about participants and their families with other Delta chapter members and Delta employees assigned to assist with youth initiative programs, on a “need to know basis.

To carry out the mission of its youth program and to better serve needs of the youth participants, the Chapter must collect certain personal information about youth participants and their families, including, but not limited to, the following “Confidential Information”:
- Name and address of participant AND Parents or Guardian
- Participant age and school
- Medical conditions / physical limitations
- Any distinguishing marks or characteristics (such as tattoos or birthmarks)
Limits of Confidentiality: Confidential information may be shared with individuals or organizations as specified below under the following conditions, and provided that the party who seeks any disclosure agrees in writing to maintain the confidentiality of the disclosed information as specified in this Confidentiality Policy:
- Delta Officers and Members of the Board have access to any participant’s files only upon directive by the International President. Any directive shall identify the person(s) authorized to review such records; the specific purpose for such review; and the period during which access shall be granted. Such Officers or Members of the Board granted access shall be required to comply with this Confidentiality Policy and may use the information only for purposes specified in the International President’s directive.
- Information may only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena or court order.
- Information may be provided to Delta’s legal counsel in the event of litigation or potential litigation involving Delta and/or the Program participants or any aspect of the Program.
- Members of the Chapter and volunteers who observe or suspect child abuse are “mandatory reporters” and, as such, must disclose suspected abuse to the proper authorities, and in making such reports, may disclose “Confidential Information.”
Safekeeping of Confidential Records: The President of the Chapter or her designee shall be the custodian of confidential records. It is her responsibility to supervise the management of Confidential Information to ensure safekeeping, accuracy, accountability, and compliance with this Confidentiality Policy.

Requests for Confidential Information by Other Agencies: Any request from other organizations or persons for Confidential Information shall be honored only if the request is accompanied by written authorization from the Parents or Guardians of the youth participant expressly permitting the release of the requested information.

Violations of Confidentiality: Known violations of this Confidentiality Policy (by volunteers or youth participants) shall be reported to the Chapter President or her designee. A violation of this Confidentiality Policy shall result in disciplinary action up to and including suspension or termination from the Program, as appropriate.

No Liability: There shall be no liability to the Chapter, or any volunteer or youth participant for disclosing information that is required to be disclosed by a court, an administrative body of competent jurisdiction, a governmental agency, or by operation of law.

APPENDIX B12

YOUTH SIGN‐IN/SIGN‐OUT POLICY

It is the policy of the local Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter") that all youth participants, members, other volunteers, and visitors must sign in and out of its Youth Initiative Program (“Program”).

The required sign-in/sign-out procedures are as follows:
- The chapter shall maintain and use a sign-in log that reflects the following: name of the youth initiative; the date; the time in and the time out; and the names of the participants, with a column for the participant and visitors to check her/their status (as member, youth, volunteer, or visitor). The form should distinguish whether a member is assisting with the Program or is a visitor/observer.
- Only authorized persons (those identified in writing) will be allowed to pick up a participant from the Program. Volunteers shall refuse to release a participant to any person, whether related or unrelated to the youth, who has not been authorized, in writing, by the Parent or Guardian to receive the youth.
One of the following procedures shall be observed during departure and return:
a. Parents or an authorized representative will sign out youth.
b. Older youth who have written Parental permission will be allowed to leave the program on their own. Members will establish a system where the youth check themselves out with an approved volunteer; the approved volunteer will ensure that the youth signed out and initialed the attendance sheet.
c. When Chapters provide transportation to off-site sponsored events, members will
develop and implement a system to ensure that all youth participating for the day board the correct bus or other vehicle at the time of departure to and return from a scheduled activity.

Failure to pick up your child at the conclusion of a session or activity will result in contact being made with the local police department and/or child protective services.

If a Parent or Guardian wishes to arrange alternative transportation for their child to attend an off-site activity, the youth may join the group at the event or activity, but the Chapter assumes no responsibility or liability for the youth participant for any non-Chapter-sponsored activity or transportation.

APPENDIX B13

INTERNET YOUTH POLICY

1. Purpose
This policy relates to the use of computers or Internet access through, during, or as part of any Delta Sigma Theta Sorority, Incorporated (“Delta”) Youth Initiative Program (“Program”) or sponsored event. The purpose of the policy is to protect the participating youth from gaining access to undesirable materials on the Internet; from making undesirable contacts over the Internet; and to prevent unacceptable use of the Internet by youth participants, including, but not limited to, using the Internet for cyber- bullying. The focus of the policy is on both personal and shared responsibility.

2. Definitions and Illustrative Examples
A. Examples of Prohibited Materials
- Pornographic images or obscene images or text on Internet websites.
- Material that contains abusive, profane, inflammatory, coercive, defamatory, blasphemous, or otherwise offensive language on websites or in e-mail messages.
- Racist, exploitative, or illegal material or messages on websites or in e-mail.
B. Examples of Prohibited Contacts
- Responding to e-mail messages or solicitations (through advertisements or web postings) from unknown or unverified parties who seek to establish a youth’s identity and/or to communicate with the youth for any purpose.
- Initiating contact with unknown or unverified parties or parties seeking to contact youth for any purposes.
C. Examples of Prohibited Contacts
- Deliberately searching for and accessing prohibited materials.
- Creating and transmitting e-mail messages that contain unacceptable language or content, such as that listed above in 2A, bullet 2; and
- Creating and publishing Internet materials that contain unacceptable language and content.
D. Examples of Cyber‐bulling
Cyber-bullying includes, but is not limited to, the following misuses of technology:
harassing, teasing, intimidating, threatening, or terrorizing another individual by way of any technological tool, such as sending or posting inappropriate or derogatory email messages, instant messages, text messages, digital pictures or images, or website postings which has the effect of:
- Physically, emotionally, or mentally harming an individual.
- Placing an individual in reasonable fear of physical, emotional, or mental harm.
- Placing an individual in reasonable fear of damage to or loss of personal property; or
- Creating an intimidating or hostile environment that substantially interferes with an individual’s educational opportunities.
3. Unintentional Exposure of Youth to Prohibited Materials on the Internet
It is Delta’s policy that Chapters must undertake every reasonable step to prevent exposure of youth participants to undesirable materials on the Internet. It is recognized that this can happen not only through the youth deliberately searching for such materials, but also unintentionally when a justifiable Internet search yields unexpected results.
To prevent such occurrences the Chapter shall adopt the following practices:
A. Chapters should use an Internet Provider or software that blocks access by:
- Filtering sites by a grading process, and
- Filtering sites by language content and prohibit sites with unacceptable vocabulary.
B. Chapters must strictly supervise Internet usage:
- Adults must strictly supervise youth participant’s Internet activity, and there should be no searching of the Internet without a supervisor checking periodically during use and reviewing the sites accessed after a youth logs off.
- Install appropriate language filtering software (e.g., Net Nanny).
4. Intentional Access of Prohibited Materials by Youth

Chapters shall explain clearly and firmly to the youth that they are prohibited from intentionally accessing prohibited material on the Internet. The youth also must be informed that if she/he violates this policy, she/he will be disciplined, and her/his Parents or Guardian will be notified. Chapters must follow through with disciplining the youth and notifying the Parents or Guardians.

5. Deliberate Access to Prohibited Materials by Adults

Adults are prohibited from deliberately accessing prohibited materials. Any adult who violates this policy will be terminated as a volunteer.

6. Receipt and transmission of e-mails by youth

It is recognized that, even with training and supervision, youth may receive or transmit e-mail messages that contain unacceptable (or even prohibited) language or content. It is also recognized that some people may try to use e-mail to identify and contact children for unacceptable reasons.

To avoid these problems, Chapters should adopt the following practices:

A. Use an Internet e-mail service that guarantees the bona-fide nature of e-mail communicants and that vets youth’s e-mail for undesirable content.

B. Depending on the circumstances and the age or maturity of the youth, allow youth to read email messages only when an adult is present or when the messages have been previewed by an adult.

C. Take steps to verify the identity of anyone seeking to establish regular e-mail communications with youth.

D. Allow youth to send e-mail messages only when the contents have been approved by an adult.

If staff or volunteers believe that youth have been targeted with e-mail messages by parties with criminal or inappropriate intent, immediately take the following steps: retain the messages; record the incident by completing the Risk Management incident Report form; inform the youth’s Parents; report the incident to law enforcement or other local or state authorities, and report the incident to the Chapter President and the Regional Director.

7. Publishing Materials on the Internet
No materials, whether created by volunteers or youth participants, that contain any prohibited images, language, or content shall be published on the Internet. Infringement of this rule shall result in disciplinary action.

No materials shall be published on the Internet that reveals the identity of any youth.

8. Use of Delta’s Internet by Visitors and Guests
No visitor or guest shall be allowed to use any Delta computer.

9. Intellectual Property Rights

A. Delta’s Intellectual Property. No individual member owns any of Delta’s intellectual property (which includes any Delta logo, word(s), or phrase(s) commonly associated with, and understood to refer to, Delta, and the “look” of any Mark used to distinguish merchandise and service as being associated with or related to Delta. Thus, no member is authorized to use such property for any inappropriate or any commercial purpose (i.e., to make money from using the property or to promote other causes), or to authorize any third party to use Delta’s intellectual property for any purpose. See Delta’s Code of Conduct, Social Media Guidelines, and Primer on the Use of the Intellectual Property of Delta.

B. Third Partiers” Intellectual Property Rights. All materials on the Internet are copyrighted and/or trademarked unless copyright has been expressly waived. Delta respects the intellectual property rights (copyright, trademarks, service marks, and related rights) of third-party owners Internet materials, and Delta assumes no liability for violations of any intellectual property rights by volunteers or youth participants.

10. Parental Approval of Publication of Photographs or Other Materials
Chapters may publish photographs of youth participants on the Internet only if the Parent or Guardian has granted authorization. Depending on the nature and content, other materials may be published so long as the Parent or Guardian has given written consent. Delta must obtain the signed Photograph, Media, and Video Authorization Form from the Parents/Guardians of a youth before publishing any content that includes images of a youth participant (Appendix B2).

APPENDIX B10

PARENT/GUARDIAN ACKNOWLEDGEMENT OF INFORMATIONAL FORMS

The Parent/Guardian forms listed below are for informational purposes and do not require a signature. By initialing the forms on the chart below, I acknowledge receipt of the form and that I have read and understand the information provided. Please retain Appendix B10 with the forms that are signed and returned.

Youth Participant Name: {participantName}

Parent/Guardian Name: {parentGuardian13}

Date: {date194}

FORM NUMBER: FORM/WAIVER*

	PARENT/GUARDIAN INITIALS
B11 : Confidentiality Policy
B12: Youth Sign‐In/Sign‐Out Policy
B13: Internet Youth Policy

Should be Empty:

Delta Youth Programs Application

Participant Information

School Information

Parent/ Legal Guardian Information

Parent/ Legal Guardian #2 Address (if the address is the same as Parent/Guardian#1)

RISK MANAGEMENT FORMS

APPENDIX B1 PARENTAL/GUARDIAN AFFIRMATION WAIVER AND RELEASE

APPENDIX B2 PHOTOGRAPH, MEDIA, AND VIDEO AUTHORIZATION RELEASE FORM

APPENDIX B3 YOUTH CODE OF CONDUCT FOR IN‐PERSON MEETINGS

APPENDIX B4 YOUTH PICK‐UP AUTHORIZATION

APPENDIX B5 PARENT WAIVER AND PERMISSION TO TRANSPORT

If the youth is NOT a license driver, skip Appendix B6a and Appendix B6b.

If the youth is NOT a license driver, skip Appendix B6a and Appendix B6b.

APPENDIX B8 MEDICAL AND EMERGENCY CONTACT INFORMATION

Below please check any current health conditions that may require attention during the Program day.

EMERGENCY CONTACT