Debutante Application

Debutante Ball Application

To Be Completed by the Debutante Ball Student Participant

PLEASE CAREFULLY READ THE FOLLOWING STATEMENT: All eligibility criteria must be maintained throughout the Debutante Season. Updated transcripts will be requested during the 2nd semester. The Dayton Alumnae Chapter of Delta Sigma Theta Sorority, Inc. reserves the right to dismiss those who fail to maintain eligibility. No refunds will be issued.
Name*

First NameLast Name
Age*
Birthdate *
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 First and Last Name*
Parent 1 Email*
example@example.com
Parent/Guardian 2 First and Last Name
Parent 2 Email
example@example.com

School/Academic Related Questions
School Now Attending*
Cumulative Grade Point Average (6 semesters)*
Date of Graduation*
Career/Future Plans *
School/Activities*
Honors and Awards (In and Out of school)*
Community/Church Involvement/Activities, etc.*
Please Upload Transcripts and Letters of Recommendation*

Cancelof
Student Signature*

Clear
Date*

MonthDayYear
Date

To Be Completed By Parent/Guardian

Please give the name and other information of the person, other than the applicant, to whom all Debutante correspondence should be sent. The person listed should be the legal guardian or financially responsible adult of the student applying to participate in the Debutante process. A written statement from the legal guardian, providing permission to communicate with the identified financial person, is requested.
Parent/Guardian 1 First and Last Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date

Media Release Form

Must be completed by the parent(s) or legal guardian(s) of the participant.
I/We Parent/Guardian Name (s)* (“Parent/Guardian”), as parent(s) or legal guardian(s) of First Name* Last Name* (Child) permit the Dayton Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (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 the Debutante Ball Youth Initiative Program activities, without payment or any consideration and without notifying me in advance. I/We also give permission for the Chapter to highlight my child’s achievement and activities in efforts to promote the youth initiative program through newspapers, radio, TV, the web, DVD’s displays, brochures, and other types of media without payment or any consideration and without notifying me. I/We understand and agree that those images will become the property of the Chapter, which shall have complete ownership of the Images. I hereby irrevocably authorize the Chapter to publish or distribute these. Images for the purpose of publicizing the Chapter’s programs, including the Debutante Ball 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 my rights to royalties or other compensation arising out of or related to the use of the Images. I/We 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; 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 be maliciously caused, produced, and published solely for the purpose of subjecting my child to conspicuous ridicule, scandal, reproach, scorn, and dignity. I/We hereby certify that I/We are the parent(s)/guardian(s) of First Name* Last Name* I/We are authorized to give consent without reservations to the foregoing on behalf of my/our child.
Parent/Guardian 1 Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian 2 Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Debutante Ball Application

To Be Completed by the Debutante Ball Student Participant

School/Academic Related Questions

To Be Completed By Parent/Guardian

Media Release Form