2024 - 2025 Youth Initiative Application

Mid-Hudson Valley Alumnae Chapter

Delta Sigma Theta Sorority, Inc.
2024 - 2025 Youth Initiative Application

PACKET # 1
Dr. Betty Shabazz Delta Academy

“Embracing Girl Power on Purpose” for girls ages 11-14
Dr. Jeanne L. Noble Delta GEMS Institute

“Jewels in our Galaxy” for girls ages 14-18
Personal Information
Participant's Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred method of communication*
Date of Birth*

MonthDayYear
Age*
Grade *
School Attending 2024 - 2025*
Please select a program*
Parent/Guardian Information
Parent/Guardian Name*

First Name, Middle InitialLast Name
Relationship to participant*
Phone Number*
Please enter a valid phone number.
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact Name

First Name, Middle InitialLast Name
Relationship to participant
Phone Number
Please enter a valid phone number.
Parent/Guardian Affirmation
I First Name, Middle Initial* Last Name* hereby give my permission for First Name, Middle Initial* Last Name* to participate in the Mid-Hudson Valley Alumnae Chapter of Delta Sigma Theta Sorority, Inc. youth initiative program and all planned activities. And, I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation.
Signature: First Name Last Name
blanksblank
Date*

MonthDayYear
Today's Date
Waiver and Release
I, First Name, Middle Initial* Last Name*, Parent/Guardian, on behalf of First Name, Middle Initial Last Name("Participant/Minor Child") do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Incorporated (“DST”), its officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, and assigns (collectively “Releases”), from any and all claims, demands, and actions of any and every kind directly or indirectly arising out of, or relating in any respect to Participant Minor Child’s participation in the Delta Academy/Delta GEMS Youth Initiative.

My waiver and release of all claims, demands, actions, and liability shall include without limitation, any injury, illness, death, property damage or loss to the Participant Minor Child which may be caused by any act, or failure to act, by the Releases, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of any Releases.

I understand that, without limitation of the foregoing, neither Delta, nor the Program, shall be liable and each is hereby released from all claims that may arise from loss or damage to the Participant Minor Child’s personal property.
Signature: First Name Last Name
Date*

MonthDayYear
Today's Date
PHOTOGRAPH, MEDIA AND VIDEO AUTHORIZATION RELEASE
I First Name, Middle Initial* Last Name*("Parent/Guardian") parent/guardian of First Name, Middle Initial* Last Name* give permission for Mid-Hudson Valley Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to publish on the Internet or media still photographs or moving images, including, if applicable any sound recordings accompanying the images (“Images”) taken of my child during participation in Youth Initiative Program activities, without payment or any consideration and without notifying me in advance.

I also give permission for the Chapter to highlight my child’s achievements and activities in efforts to promote the youth initiative program through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media without payment or any consideration and without notifying me.

I understand and agree that these Images will become the property of the Chapter, which shall have complete ownership of the Images. I hereby irrevocably authorized the Chapter to publish or distribute these Images for the purpose of publicizing the Chapter’s programs, including the Delta Academy/Delta GEMS Youth Initiative Program or for any other lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my child’s likeness appears. Additionally, I waive any rights to royalties or other compensation arising out of or related to the use of the Images.

I hereby hold harmless and release and forever discharge the Chapter and any of its officers and members; Delta Sigma Theta Sorority, Incorporated; its officers; National Executive Board; employees; members; representatives; agents; and assigns from any and all claims, costs, suits, actions, judgments, and expenses which my child, his/her heirs, representatives, executors, administrators, or any other persons acting on his/her behalf have or may have by reason of the use of the Images. This release specifically includes, without limitation, a complete release and discharge of any liability by virtue of any editing, distortion, alteration, or optical illusion, whether intentional or otherwise, that may occur or be produced in the taking of or editing of said Images, unless it can be shown that such was maliciously caused, produced and published solely for the purpose of subjecting my child to conspicuous ridicule, scandal, reproach, scorn and indignity.

I hereby certify that I am the parents/guardian of First Name, Middle Initial* Last Name* and am authorized legally to give this consent, and do hereby give my consent without reservation to the foregoing on behalf of my child/the participant
Signature: First Name Last Name
Date*

MonthDayYear
Date
YOUTH CODE OF CONDUCT
1. Respect all participants (other youth and adult volunteers) by not using foul, hurtful or obscene language or engaging in physical violence, bullying (including cyber-bullying)1 or other aggressive behaviors that threaten the safety of others.
2. Respect the property rights of others. 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-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

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.
Participant Acknowledgement of 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-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

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.
Participant's Signature: First Name Last Name
Date*

MonthDayYear
Date
Parent/Guardian Acknowledgement of 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-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

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.
Signature: First Name Last Name
Date*

MonthDayYear
Date
YOUTH PICK-UP AUTHORIZATION

I authorize the person(s) listed below to pick-up my child from the Delta Academy/Delta GEMS 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).
Participant's Name

First Name, Middle InitialLast Name
Authorized Person's Name

First Name, Middle InitialLast Name
Relationship to participant
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Authorized Person's Name

First Name, Middle InitialLast Name
Relationship to participant
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Authorized Person's Name

First Name, Middle InitialLast Name
Relationship to participant
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Authorized Person's Name

First Name, Middle InitialLast Name
Relationship to participant
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Authorized Person's Name

First Name, Middle InitialLast Name
Relationship to participant
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
By signing below, I verify that I have read and agree to the Student Pick-Up policies described above and authorize the Mid-Hudson Valley Alumnae Chapter to release my child to the persons listed above. I also agree to notify the Mid-Hudson Valley Alumnae Chapter in writing of any changes to the above list of authorized persons.
Signature: First Name Last Name
Date*

MonthDayYear
Date
PARENT WAIVER AND PERMISSION TO TRANSPORT YOUTH
Participant's Name

First Name, Middle InitialLast Name
Event Name
Event Location
Driver's Name

First Name, Middle InitialLast Name
I give permission for my child/charge (“child”) to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver.

I have read, understand, and discussed with my child that:
1. They will be traveling in a motor vehicle driven by an adult, and they are to wear their safety-belt while traveling.
2. They are expected to respect the vehicles they ride in, and the person they travel with during the trip.
3. Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and
4. They are to remain in their seats and not be disruptive to the driver of the vehicle.
I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the

Mid-Hudson Valley Alumnae Chapter from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.
Signature: First Name Last Name
Date*

MonthDayYear
Date
PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORTYOUTH

ALL TEENAGE DRIVERS MUST HAVE A NON-PROVISIONAL DRIVER’S LICENSE
I give permission for my child/charge (“child”) to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver.

I have read, understand, and discussed with my child that:
1. They will be traveling in a motor vehicle driven by an adult, and they are to wear their safety-belt while traveling.
2. They are expected to respect the vehicles they ride in, and the person they travel with during the trip.
3. Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and
4. They are to remain in their seats and not be disruptive to the driver of the vehicle.
I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the

Mid-Hudson Valley Alumnae Chapter from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.
Signature: First Name Last Name
Date*

MonthDayYear
Date
OFF-SITE PERMISSION
I First Name, Middle Initial Last Name (“Parent/Guardian”), as parent(s) or legal guardian(s) of First Name, Middle Initial Last Name (“Child”), give permission for my/our Child to participate in the Delta Academy/Delta GEMS Youth Initiatives Program’s (the “Initiatives”) activities taking place off site. I/we understand that transportation to and from these activities will be provided for my/our Child by the Chapter.

I understand that the field trips are part of the Initiatives and if I/we choose to not have my/our Child participate in one or more off-site activities, I/we must make other care arrangements for my/our child during the times of that field trip activity.

I assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, except for gross negligence or intentional infliction of harm by the Initiatives, its officers, agents or employees.

I do hereby agree to release and hold harmless the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns from any and all claims, costs, suits, actions, judgments, and expenses for any damage, loss, or injury to my/our child or damage to my/our child’s property arising from my/our child’s participation in field trips, other than damage, loss, or injury that results from gross negligence or intentional infliction of harm by the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns.
Signature: First Name Last Name
Date*

MonthDayYear
Date
Should be Empty:

Mid-Hudson Valley Alumnae Chapter

2024 - 2025 Youth Initiative Application

Dr. Betty Shabazz Delta Academy

Dr. Jeanne L. Noble Delta GEMS Institute

Personal Information

Parent/Guardian Information

Parent/Guardian Affirmation

Waiver and Release

PHOTOGRAPH, MEDIA AND VIDEO AUTHORIZATION RELEASE

YOUTH CODE OF CONDUCT

Sanctions for Violating Code of Conduct

Participant Acknowledgement of Code of Conduct

Parent/Guardian Acknowledgement of Code of Conduct

YOUTH PICK-UP AUTHORIZATION

PARENT WAIVER AND PERMISSION TO TRANSPORT YOUTH

PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORTYOUTH

OFF-SITE PERMISSION