Youth Initiative Application

YOUTH INITIATIVE APPLICATION
Participant Information
I am applying for*

Delta Academy (ages 11-14)Delta GEMS (ages 14-18)
Folder Name
Name*

First NameMiddle NameLast Name
Name in Form*
Age*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #
Cell #*
Email*
example@example.com
Current School*
Grade*
After School/Community/Religious Involvement*
I would like to pursue a career in*
T-shirt Size (Adult Sizes)*

XSSMLXL2XL
Parent/Guardian Information
Primary Caregiver*

MotherFatherLegal Guardian
Mother's Name

PrefixFirst NameMiddle NameLast Name
Mother’s Name in Form
Mother's Work #
Mother's Cell #
Mother's Email
example@example.com
Father’s Name

PrefixFirst NameMiddle NameLast NameSuffix
Father’s Name on Form
Father's Work #
Father's Cell #
Father's Email
example@example.com
Guardian’s Name

First NameMiddle NameLast NameSuffix
Guardian’s Name on Form
Guardian's Work #
Guardian's Cell #
Guardian's Email
example@example.com
Emergency Contact*

PrefixFirst NameMiddle NameLast NameSuffix
Emergency Contact on Form
Emergency Contact's Work #
Emergency Contact's Cell #*
Emergency Contact's Relationship*
Additional Demographic Information
Number of adults in the household*
Number of school-aged children in the household*
Do you receive free/reduced lunch?*

YesNo
Do you have a sibling that is currently in Delta GEMS/Delta Academy?*

YesNo
Is your mother a member of Delta Sigma Theta Sorority, Inc.?*

YesNo
I grant permission for my child to participate in the St. Petersburg Alumnae Chapter of Delta Sigma Theta Sorority Incorporated Youth Initiative program.
Parent/Guardian Signature*

Clear
Parent/Guardian Print Name*
Date*

MonthDayYear
Date
Should be Empty:

YOUTH INITIATIVE APPLICATION

Participant Information

Parent/Guardian Information

Additional Demographic Information