2024-2025 Dr. Betty Shabazz Delta Academy Application

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9
Welcome to Delta Academy's Online Application!

We are excited that you are considering joining our mentoring group. Please take a few minutes to complete the application by Saturday, October 12, 2024.

Delta Academy Chairs:

Adrienne Burrows
Chandale Williams

The 2024 Mentorings Groups Orientation and Risk Management Training is Saturday, September 14, 2024.

Contact Us at deltaacademymac@gmail.com

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

APPLICANT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Please enter a valid phone number.
Cellular Number
Please enter a valid phone number.
Applicant Email
example@example.com
Date of Birth*

MonthDayYear
Date
T-Shirt Size*

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

PARENTAL/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Alt. Number
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian Name #2(Optional):

First NameLast Name
Contact Number
Please enter a valid phone number.
Alt. Number
Please enter a valid phone number.
Parent/Guardian Email #2
example@example.com

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

ESSAY
Are you a new member?*

YesNo, I am a returning member.
Why I would like to be a part of Delta Academy?*
Why I should I be considered for Delta Academy for another year?*
Please upload a copy of your 2023-2024 School Year Report Card. In addition, if you are a part of other organizations and/or extra curricular activities, such as Top Teens of America, Girl Scouts, Sports, etc. please upload your calendar of events.*

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2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

EMERGENCY CONTACT INFORMATION
Emergency Contact #1*

First NameLast Name
Relationship*
Home
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Emergency Contact #2

First NameLast Name
Relationship
Home
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
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

First NameLast Name
Relationship
Home
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
In the event that 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 any and all expenses incurred and authorize the medical facility at which treatment is rendered to release all necessary information to my/our insurance company.
Parent/Guardian Signature*

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Date*

MonthDayYear
Date

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9
Youth Pick-up Authorization Form
I, parent/guardian name , authorize the persons listed below to pick-up my child from the DELTA ACADEMY 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. (Please include names of either parents or guardians on list below).
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9
CODE OF CONDUCT FOR YOUTH
PARTICIPATING IN YOUTH INITIATIVES PROGRAM
1. Respect all participants (other youths and adult volunteers) by not using foul, hurtful or obscene language or engaging in physical violence, bullying (including cyber-bullying)₁or other aggressive behaviors that threaten the safety of others.
2. Respect the property rights of other. 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 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-day suspension from program
4th Time: 1-week suspension from program
Next occurrence youth is removed from the program.

Physical Violence and Other Misconduct:
1st Time: Removal from situation, loss of privileges, guardian notified from this point forward
2nd Time: 1-day suspension from program
3rd Time: 1-week suspension from program
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.

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.
Participant's Name*

First NameLast Name
Participant's Signature*

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Date*

MonthDayYear
Date
**************

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 Delta Academy program. I agree that the sanctions for violating the Code of Conducts are reasonable and will help my child comply.
Parent's Name*

First NameLast Name
Parent's Signature*

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Date*

MonthDayYear
Date

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9
DELTA SIGMA THETA YOUTH INITIATIVE SIGN IN/SIGN OUT POLICY

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

The required sign in/sign out procedures follow:
1. The chapter shall maintain and use a daily 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.
2. 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.
3. 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 initial the attendance sheet.

c. When chapters provide transportation to offsite 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.

Chapters should clearly communicate to parents or guardians that, if a parent or guardian wishes to arrange alternative transportation for their child to attend an offsite activity, the youth may join the group at the event or activity, but the Miami Alumnae Chapter assumes no responsibility or liability for the youth participant for any non-chapter-sponsored activity or transportation.
Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

Youth Pick-up Authorization Form

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9

2024-2025 Application

Dr. Betty Shabazz Delta Academy

For Young Girls in Grades 6-9