SAC Education Program Application Form

SAC Education Program Application Form

This is for applicants for the Dr. Betty Shabazz Delta Academy and Dr. Jeanne L. Noble Delta G.E.M.S. programs | Delta Sigma Theta Sorority, Incorporated
Date

MonthDayYear
Date
Participant Name*

First NameLast Name
Participant DOB*
Participant Age*
Participant Grade (2025-2026 School Year)*
Participant School (2025-2026 School Year)*
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Phone Number*
Please enter a valid phone number.
Participant Email*
example@example.com
T-shirt/Hoodie Size*
How did you learn about Delta Academy?
How did you learn about Delta GEMS?
Please list your extra-curricular activities, including any known scheduling conflicts between October to June (e.g. on a sport team, family trips, homecoming, memberof school band or cheer squad, etc):*

Parent/Guardian Name*

First NameLast Name
Relationship to applicant:*
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian 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 challenges or areas of growth that require additional or unique support? 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. *
ACADEMY 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.
GEMS PARENT/LEGAL GUARDIAN VERIFICATION:
My signature below certifies that I authorize my daughter's participation in the Seattle Alumnae Chapter Delta GEMS Program and activities. I give/do not give (circle one) my permission for my daughter’s image to be used on Seattle Alumnae Chapter’s, Farwest Region’s or Delta Sigma Theta Sorority, Inc’s website, Facebook page and Twitter account. I will notify GEMS chairs at deltagems@seattledeltas.org if my daughter will miss a session.
Parent/Guardian Signature*

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