2024-2025 EMBODI Application

EMBODI Application 2024-2025
Dear Parent/Guardian:

The Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc. invites you to join our 2024-2025 EMBODI - Empowering Males to Build Opportunities for Developing Independence – Program where participants ages 11 to 18, will participate in activities, community service and educational workshops. Participants are expected to attend meetings from September 2024 through April 2025. We are excited about the program and have planned a wonderful experience for the young males who participate!

The goals of EMBODI are:
- To expand the horizons of young African American males by cultivating a personal vision for their lives.
- To provide tools for participants to attain a higher quality of life.
- To provide participants with an awareness of various college and career options to make rewarding life choices and decisions.
- To create community-minded participants by actively involving them in service learning and community service opportunities.
If you would like your young man to become a part of this rewarding program, please complete this application in its entirety.

During each program day, participants will be asked to stow away cell phones to encourage and solicit active participation. In the event of an emergency, please contact either Co-Chair via cell phone. We will ensure any pertinent information is communicated with your youth upon making contact.

Further information will be shared at the EMBODI Participant Orientation and Kickoff on Saturday, September 14th, 2024, from 10:00 am to 12:00 pm. Parents/guardians must be in attendance for this kickoff meeting. If you have any questions, please feel free to email the EMBODI team at dstjaxembodi@gmail.com.

Sincerely,

Keisha Bird & Nyiha Williams

EMBODI Co- Chairs EMBODI
Student Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade Level*
School Name*
Please provide full name of school
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Family/Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select your preferred method(s) of contact*

Phone CallText MessageEmail
Health Insurance Provider*
Policy Holder Name*
Policy #*
Physician Name*
Physician Phone Number*
Please enter a valid phone number.
Please list two emergency contacts with full name, phone number and relationship to the applicant below.*
Please list all adults, other than Parent/Guardian, authorized to sign the participant in and out of program days or other events sponsored by the Jacksonville (FL) Alumnae Chapter including their full name, phone number and relationship to the applicant.*

Participant Application Form
Favorite Subjects in School
Extracurricular Activities
Hobbies
What are your talents?
What do you do best and/or like to do?
What do you want to gain from participating in the EMBODI program?
What new subjects do you like to learn about?

PROGRAM LIABILITY WAIVER

This signed agreement officially absolves the Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc. and the Grand Chapter of Delta Sigma Theta Sorority, Inc. of any and all liability from any accidents or injuries resulting from you or your child’s participation in any activity or event.

Furthermore, it is understood that any and all medical expenses incurred due to injuries sustained at any activity or event organized by the Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc. is the sole responsibility of the participant in the activity or event and if a minor, the parent or guardian. This is inclusive of pre-existing conditions, which may become aggravated due to you or your child’s participation in any activity or event.

It is also understood that no legal action will be brought against Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or subsidiaries or authorized personnel by you or your child because of any matter directly or indirectly related to you and your child’s participation in any activity or event held by the Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc.

As a parent/guardian of the above-referenced applicant/participant, I request he attend EMBODI, and take part in all activities and events. I hereby give my consent to any field trip my son may take while attending EMBODI. In case of emergency the committee leader, sub-leader or their representative has my permission to give minor first aid or take my child to an emergency treatment facility.

I, parent/guardian further request the committee leader, sub-leader or their representative to call a physician for medical care for my child should an emergency arise. I understand that the program staff will make a conscientious effort to locate me via the telephone number(s) provided at registration as well as attempting to contact me before any action is taken but if it is not possible to locate me, I understand that I will accept all medical expenses.

By signing your name, you are stating that you have read and fully understand and are in agreement with this waiver.
Signature of Parent/Guardian*

Clear
MEDIA WAIVER

I, the parent/guardian of the above-referenced applicant/participant consent to the release of photographs, videos, audio and other related recorded materials captured during the scholarship awards program. Such materials shall remain the sole property of the Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc. and shall not be sold to any entity.

BY MY SIGNATURE, I AM INDICATING THAT I HAVE READ AND UNDERSTAND THE FOREGOING INFORMATION.
Signature of Participant

Clear
Signature of Parent/Guardian

Clear
Please type your full name below if you DO NOT consent to the release of photos.
Please list any allergies to food or drugs.
Please list any illnesses, medications, medical conditions (i.e. diabetes) or physical limitations that the EMBODI committee members should be aware of:
EMODI Parent Consent Form

By my signature below, I hereby verify that the above information is accurate. My signature grants permission for my child to participate in the Empowering Males to Build Opportunities for Developing Independence (EMBODI) Program, field trips, and acivities therein. In giving my permission to participate, I understand that he will take part in scheduled meetings, workshops, cultural, educational and recreational programs. I agree to provide transportation for my child to all scheduled meetings and activities. I also agree to facilitate and support my child's timely attendance and participation.

I agree not to hold the Jacksonville (FL) Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or the EMBODI Program and its members responsible and/or liable for any injuries or illnesses that my child may sustain while in attendance at the sessions of the EMBODI Program. I also agree not to hold the above-named organization, or its members or appointees individually, liable for the loss or destruction of my child's property.
Signature*

Clear
Should be Empty:

EMBODI Application 2024-2025

Student Information

Family/Contact Information

Participant Application Form