2024-2025 RHPVACDST Academy GEMS Application

2024-2025 Parental Consent Form

RHPVACDST Delta Academy and Delta G.E.M.S.
Parent/Guardian Name*

First NameLast Name
Relationship to Applicant*
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Relationship to Applicant*
Emergency Contact Phone Number*
Please enter a valid phone number.
By signing below, I hereby verify that the above information is true and accurate. The undersigned grants permission for the applicant to participate in monthly virtual meetings and activities therein and will facilitate the child’s timely attendance and participation.

I agree not to hold the Rolling Hills / Palos Verdes Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or the Delta G.E.M.S. and its members responsible and liable for an injuries or illnesses that my child may sustain while in attendance at the sessions of the program. I also agree not to hold the above-named organizations, its members or appointees individual liable for the loss or destruction of my child’s property.
Parent/Guardian Name*

First NameLast Name
Consent to Participate - Parent / Guardian Signature*

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Signature Date*

MonthDayYear
Date

2024-2025 Consent to Photograph

RHPVACDST Delta Academy and Delta G.E.M.S.
Please Read Carefully and Sign Below

I, give permission for my daughter, to be photographed and/or videotaped throughout the Delta Academy / Delta G.E.M.S. program sponsored by the Rolling Hills / Palos Verdes chapter of Delta Sigma Theta Sorority, Incorporated.

Virtual meetings: I understand that if and when meetings are held virtually, they will take place on the Zoom web-conferencing platform. My child is expected to keep their camera on and have a working microphone to fully engage and participate in virtual activities.

In-person meetings: If there are in-person meetings, I understand that pictures may be taken to capture memories of our programs activities and shared on our social media platforms, such as Instagram and Facebook.

By signing below, I consent to the use of her likeness in any publication, educational material, advertising, news media, and World Wide Web materials that the Delta Academy / Delta G.E.M.S. may utilize and produce.

I understand and agree that such materials, including all digital images, and prints shall become and remain the sole property of Dr. Betty Shabazz Delta Academy / Dr. Jeanne L. Noble Delta G.E.M.S. and I shall have no right or title to such items. I further understand and agree that these materials may be kept on file and used for potential future use. I agree to release the Dr. Jeanne L. Noble Delta G.E.M.S. from any and all liability arising from or in connection with the taking, use of publication, or dissemination of such materials.
Do you give photograph consent for our chapter to capture workshop memories through photographs that may or may not be shared on our chapter's social media platforms, such as Instagram and Facebook?*

I do give permission.I do not give permission.
If you do give parental consent to photograph our activities that may include your daughter's picture, please sign below.
Parent/Guardian Name*

First NameLast Name
Consent to Photograph - Parent/Guardian Signature

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Delta Sigma Theta Sorority, Inc. is a private, non-profit organization whose purpose is to provide assistance and support through established programs in local communities throughout the world. A sisterhood of more than 200,000 predominantly Black college educated women, the Sorority currently has over 900 chapters located in the United States, England, Japan (Tokyo and Okinawa), Germany, Hawaii, the Virgin Islands, Bermuda, the Bahamas and the Republic of Korea. The major programs of the sorority are based upon the organization’s Five Point Programmatic Thrust: Economic Development, Educational Development, International Awareness and Involvement, Physical and Mental Health, and Political Awareness and Involvement.

For more information about Delta Sigma Theta Sorority, Inc. visit: www.deltasigmatheta.org

The Sorority was founded in 1913 by 22 students at Howard University. These young women wanted to use their collective strength to promote academic excellence; to provide scholarships; to provide support to the underserved; educate and stimulate participation in the establishment of positive public policy; and to highlight issues and provide solutions for problems in their communities. The Rolling Hills/Palos Verdes Alumnae Chapter continues this legacy of service to the community.

Chartered on January 14, 2001, the Rolling Hills/Palos Verdes Alumnae chapter became the 941st chapter of the Sorority and is comprised of residents of the Palos Verdes Peninsula and surrounding South Bay communities. In serving the communities of Torrance, Lomita, Redondo Beach, Manhattan Beach, Hermosa Beach, Lawndale, Gardena, Hawthorne, Rancho Palos Verdes, Wilmington (Los Angeles), El Segundo, Harbor City and San Pedro the Rolling Hills/Palos Verdes Alumnae chapter of Delta Sigma Theta Sorority, Inc. continues to “Transform Lives and Impact Communities.” Since the chartering of the Rolling Hills /Palos Verdes Alumnae Chapter, over $100,000 in college scholarships have been awarded to more than three dozen young women and men in the South Bay communities of Los Angeles. Our Torchbearer’s Foundation has been able to support various organizations including the Harbor UCLA Black Infant Health Project, 731 Family Crisis Center, Torrance Care Center, Harbor Interfaith Services, Jenesse Center, Inc., Harbor Village Housing Project Obesity Action Coalition, Abundant Life Orphanages, and the Family to Family Africa Project. The chapter has also been a benefactor for the Howard University Endowment Chair, Scholarships to the United Negro College Funds, Scholarships to Local Church Youth Departments, and the Delta Research and Education Foundation.

For more information about our chapter, go to www.rhpvacdst.com
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Dr. Betty Shabazz Delta Academy & Jeanne L. Noble Delta GEMS Institute

2024-2025 Parental Consent Form

2024-2025 Consent to Photograph