PGCAC Youth Group Student Application Form 2024-2025

PGCAC Youth Group Student Application Form 2024-2025
Student Contact Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
School*
Grade Level*
Last Grade Point Average
Address*
City*
State*
Zip Code*
Cell Number
Home Number
E-mail Address*
example@example.com
Please select the PGCAC Youth Group to which you are applying*

Dr. Betty Shabazz Delta Academy (Females: Ages 11 - 14)Delta GEMS (Females: Ages 14 - 18)EMBODI (Males: Ages 14 - 18)
Parent(s)/Guardian(s) Contact Information
Parent/Guardian 1 Name*
Parent or Guardian Name
Cell Number
E-mail Address*
example@example.com
Parent/Guardian 2 Name
Parent or Guardian
Cell Number
E-mail Address
example@example.com
PGCAC Youth Group Student Application Form 2024-2025
Student Information
1. Favorite school subjects:
2. List extracurricular activities (including school, community or church activities):
3. Hobbies/Talents:
4. What are your plans/goals after high school?
5. Are you a previous Youth Group participant?

YESNO
6. Have you ever participated in a mentoring program(s)?

YESNO
If so, please give the name of the program(s):
7. How did you hear about our Youth Programs?
PGCAC Youth Group Student Application Form 2024-2025
8. List suggested topics that you would like to discuss this year:
8. a. Suggested Topics
9. List activities or community service projects you would like to participate in this year:
9.a. Activities and/or Community Service Projects
10. Please upload a 3x5 headshot photo in gif, jpg, png format only.
All Dr. Betty Shabazz Delta Academy and Delta GEMS applicants must answer the essay topic below. The essay must be legibly hand-written (do not use pencil) or typed and submitted along with your application. Your essay must be between 150 and 200 words in length.

1. Describe why you want to participate in the Prince George’s County Alumnae Chapter’s Youth Program, and what experiences would you like to gain by participating.

Note: Please remember to state the program to which you are applying.
Prince George’s County Alumnae Chapter Delta Sigma Theta Sorority, Incorporated Youth Group Student Application Form 2024-2025
Short Essay (150 – 200 Words)*

0/200
PGCAC Youth Group Student Application Form 2024-2025
Application Submission
All applications, and required supporting documents/attachments, must be completed, signed and submitted, along with a 3x5 photo, no later than Monday, September 30, 2024 to the appropriate e-mail address:

Dr. Betty Shabazz Delta Academy:
Bettyshabazz@pgcacdst.org

Delta GEMS:
Deltagems@pgcacdst.org

EMBODI:
EMBODI@pgcacdst.org

Please note: If you are selected for the program, you and your parent MUST attend the Kick- off/Orientation session scheduled for Saturday, September 21, 2024. Notification of acceptance will come through e-mail.

By my signature below, I hereby verify that the above information is accurate. YOU MUST SIGN and DATE this application.
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
For official use only:
Date Received:
Should be Empty:

PGCAC Youth Group Student Application Form 2024-2025

Student Contact Information

Parent(s)/Guardian(s) Contact Information

PGCAC Youth Group Student Application Form 2024-2025

Student Information

PGCAC Youth Group Student Application Form 2024-2025

Prince George’s County Alumnae Chapter Delta Sigma Theta Sorority, Incorporated Youth Group Student Application Form 2024-2025

PGCAC Youth Group Student Application Form 2024-2025

Application Submission

For official use only:

Date Received: