Dr. Betty Shabazz Delta Academy Application
“Embracing Girl Power on Purpose”
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
School
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Grade Level
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5th
6th
7th
8th
9th
Please use the space below to tell us about your involvement in school and the community.
School Involvement (i.e. math club, cheerleading, track, etc.):
*
Community Service, Hobbies, Interests:
*
Your current career goals:
*
Please write a one page essay describing “Why you want to join the Delta Academy?” Please include what you would like to get out of the academy.
*
Statement of Integrity/Commitment
As a participant, I hereby agree to participate in the 2024-2025 Dr. Betty Shabazz Delta Academy. I will attend at least 90% of the scheduled events for the year. I agree that I will actively participate in the activities created, to help me learn more about the world, and myself. I hereby state that by signing this document that all work turned in to the program for selection is my original work. If plagiarism or undue assistance is discovered, I understand that I will be asked to leave the program. As a parent, I hereby agree to be an active supporter of the Delta Academy, by transporting my child to Delta Academy meetings and/or activities, reinforcing the lessons taught at the academy, and to be actively involved in my child’s quest to become better.
Applicant's Signature
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Date
*
-
Month
-
Day
Year
Date
Parent/Guardian's Signature
*
Date
*
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Month
-
Day
Year
Date
Parent/Guardian Information:
Name
*
First Name
Last Name
Cell Phone Number:
*
Please enter a valid phone number.
Alternate Phone Number:
*
Please enter a valid phone number.
Email Address:
example@example.com
MEDICAL RELEASE/ EMERGENCY CONTACT INFORMATION
Please list any known allergies and describe any physical limitations of the applicant:
Insurance Carrier:
Doctor's Name:
Policy #:
Group #:
Please list the names and phone numbers of those to contact in the event of an emergency (other than parents).
*
Name
Phone Number
Relationship to Applicant
Name
Phone Number
Relationship to Applicant
WAIVER AND RELEASE
*
Parent/Guardian's Signature
*
Date
*
-
Month
-
Day
Year
Date
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