2024-2025 Dr. Betty Shabazz Delta Academy Participant Application Form

Dr. Betty Shabazz Delta Academy Participant Application Form

Seattle Alumnae Chapter | Delta Sigma Theta Sorority, Incorporated
Date

MonthDayYear
Date
Name*

First NameLast Name
DOB*
Age*
Grade (2024-2025 School Year)*
School (2024-2025 School Year)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you learn about Delta Academy?*
Please list your extra-curricular activities, including any sport or tutoring schedule.*

What are your favorite and least favorite subjects? Explain why.*
Describe your strengths and areas for development.*
Tell us about your goals and aspirations.*
Do you have any hobbies and/or interests? If so, describe. *
Why do you want to be a participant in Delta Academy?*

Name*

First NameLast Name
Relationship to applicant:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact #1 (Name, Phone Number, & Relationship)*
Emergency Contact #2 (Name, Phone Number, & Relationship)
Does the applicant have any food allergies? If yes, please explain. *
Does the applicant have any differing learning abilities or special accommodations we should know about? If yes, please explain. *
Does the applicant have any health conditions we should know about? If yes, please explain. *
Does the applicant have any behavioral challenges they are working to improve? If yes, please explain. *
Is there anything else we should know about the applicant that hasn't been mentioned thus far? If yes, please explain. *
PARENT/LEGAL GUARDIAN VERIFICATION:
By my signature below, I hereby verify that the above information is current and accurate. If selected, I agree for my child to participate in the Dr. Betty Shabazz Delta Academy. It is ok for my daughter to go on walking field trips near the school and be photographed for media/Seattle Alumnae Chapter’s website. I understand it is the policy of the Seattle Public Schools that the school nurse shares medical plans with you before each field trip. I will facilitate and support my child’s regular and timely attendance and participation. I understand I must provide transportation to/from Shabazz Delta Activity sessions and that my daughter will use public or school district transportation to go on field trips chaperoned by the sorority members who work with them.
Signature*

Clear
Should be Empty: