2025-2026 MHVAC Youth Program Application
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  • Mid-Hudson Valley Alumnae Chapter

    Delta Sigma Theta Sorority, Inc.
  • 2025 - 2026 Youth Program Application

    Dr. Betty Shabazz Delta Academy & Dr. Jeanne L. Noble Delta GEMS
  • PARTICIPANT INFORMATION

  •  / /
  • PARENT/GUARDIAN INFORMATION

  • Emergency Contact Information

  • PARENT/GUARDIAN AFFIRMATION

  • I   *   *   hereby give my permission for   *   *    to participate in the Mid-Hudson Valley Alumnae Chapter's 2025-2026 youth program and all planned activities. And, I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation.

  • Waiver and Release

  • I   *   *   , on behalf   *   *   do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Inc. ("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 the participants participation in the Dr. Betty Shabazz Delta Academy and Dr. Jeanne L. Noble Delta GEMS youth programs.

    My waiver and release of all claims, demands, action, and liability shall include, without limitation, any injurie, illness, death, property damage or loss to the participant which may be caused by any act or failure to act, by the volunteers, other participants, parents, Releases or others, unless such injury, illness, death, property damage or loss is a direct result of the willfull misconduct of any of the aforementioned.


    I understand that, without limitation of the foregoing, neither Delta Sigma Theta Sorority, Inc., nor the program, shall be liable and each is hereby released from all claims that may arise from loss or damage to the participant and personal property.


  • PHOTOGRAPH, VIDEO, ALL MEDIA AUTHORIZATION RELEASE

  • I   *   *   am the parent or guardian of   *   *   and give permission for Mid-Hudson Valley Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to publish on the Internet or any 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 authorized legally to give this consent and do hereby give my consent without reservation to the foregoing on behalf of my child/the participant.

  • PARTICIPANT CODE OF CODUCT

    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 Offense: Verbal warning, parent or guardian is notified.

    2nd Offense: Loss of privileges

    3rd Offense: 1-week suspension from program

    4th Offense: Youth is removed from the program.

     

    Physical Violence and Other Misconduct:

    1st Offense: Removal from situation, loss of privileges, parent or guardian is notified.

    2nd Offense: Youth is removed from the program.

     

    Illegal Substances or Dangerous Weapons

    1st Offense: Youth is removed from the program. If a youth is in possession of an illegal substance or dangerous weapon parent, guardian and the police will be notified immediately. 

  • Our signatures affirm that we have read, understand, and acknowledge the Code of Conduct.

  • YOUTH PICK-UP AUTHORIZATION

    Complete only if applicable
  • 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.

  • PARENT WAIVER AND PERMISSION TO TRANSPORT YOUTH

    Complete only if applicable
  • I give permission for my child/charge (“child”) to be transported in a motor vehicle driven by the individual identified to and/or from youth program meetings and/or events/activities. 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.

     

    IMPORTANT NOTE: Driver(s) must meet one of the below criteria: 

    1. Match the person(s) authorized for pick-up. 
    2. Must be accompanied by the person(s) authorized for pick-up.
  • OFF-SITE ACTIVITY PERMISSION

  • I give permission for my child to participate in Delta Academy/Delta GEMS Youth Initiatives Program’s (the “Initiatives”) activities taking place off site. I understand that transportation to and from these activities are my responsibility and will not be provided by the Chapter, unless explicitly otherwise stated. In such cases, where the Chapter will provide group transportation, a separate permissions form will be provided to the parent or guardian.

    I understand that off-site activities may be part of the program and if I choose not to have my child participate in one or more off-site activities, they should be kept home during the times of the off-site activity.

    I assume all risks and hazards of loss or injury of any kind that may arise in connection with such off-site activities.

    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.

  • Health/Medical History

  • IMPORTANT! 

    IF PARTICIPANT TAKES ANY PRESCRIBED OR OVER-THE-COUNTER MEDICATION, YOU MUST COMPLETE A SEPARATE MEDICAL AUTHORIZATION FORM. 

    THIS FORM CAN BE OBTAINED BY CONTACTING:

    FOR DELTA ACADEMY:

    RACHEL JOHNSON OR NAKIA HARRIS-BROWN (CO-CHAIRS)

     

    FOR DELTA GEMS:

    VALENTINA STUBBS OR SHAWNA NEWKIRK-REYNOLDS (CO-CHAIRS)

  • If yes, I         hereby affirm that         is authorized to (self) take any necessary prescribed or over-the-counter medications as described above.

  • Emergency Contact Information

    If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.
  • In the event that the Program is unable to reach any of the individuals named above promptly by phone, I/we authorize the Program to seek and secure any emergency medical or surgical care for my/our child.

    I/We will be responsible for any and all expenses incurred and authorize the medical facility at which treatment is rendered to release all necessary information to my/our insurance company.

  • YOUTH SIGN-IN/SIGN-OUT POLICY

  • It is the policy of the Mid-Hudson Valley Alumnae Chapter, Delta Sigma Theta Sorority, Incorporated that all participants (youth, members, and other volunteers) and visitors must sign in and out of its Delta Academy/Delta GEMS Youth Initiative Program (“Program”). The required sign in/sign out procedures are as follows:

    • The chapter shall maintain and use a sign in log that reflects the following: name of the youth initiative; the date; the time in and the time out; and the names of the participants, with a column for the participant and visitors to check her/their status (as member, youth, volunteer, or visitor). The form should distinguish whether a member is assisting with the Program or is a visitor/observer.
    • Only authorized persons (those identified in writing) will be allowed to pick up a participant from the Program. Volunteers shall refuse to release a participant to any person, whether related or unrelated to the youth, who has not been authorized, in writing, by the parent or guardian to receive the youth.
    • One of the following procedures shall be observed during departure and return:
    1. Parents or an authorized representative will sign out youth.
      Older youth who have written parental permission will be allowed to leave the program on their own. Members will establish a system where the youth check themselves out with an approved volunteer; the approved volunteer will ensure that the youth signed out and initialed the attendance sheet.
    2. When Chapters provide transportation to off-site sponsored events, members will develop and implement a system to ensure that all youth participating for the day board the correct bus or other vehicle at the time of departure to and return from a scheduled activity.
      Failure to pick up your child at the conclusion of a session or activity will result in contact being made with the local police department and/or child protective services.
    3. If a parent or guardian wishes to arrange alternative transportation for their child to attend an off- site activity, the youth may join the group at the event or activity, but the
      Mid-Hudson Alumnae Chapter assumes no responsibility or liability for the youth participant for any non-chapter-sponsored activity or transportation.
    • Failure to pick up your child at the conclusion of a session or activity will result in contact being made with the local police department and/or child protective services.
    • If a parent or guardian wishes to arrange alternative transportation for their child to attend an off- site activity, the youth may join the group at the event or activity, but the Mid-Hudson Alumnae Chapter assumes no responsibility or liability for the youth participant for any non-chapter-sponsored activity or transportation.
  • INTERNET USE POLICY 

    • Purpose


    This policy relates to the use of computers or Internet access through, during, or as part of any Delta Sigma Theta Sorority, Incorporated (“DST”) Youth Initiative Program (“Program”) or sponsored event. The purpose of the policy is to protect the participating youth from gaining access to undesirable materials on the Internet; from making undesirable contacts over the Internet; and to prevent unacceptable use of the Internet by youth participants, including, but not limited to, using the Internet for cyber- bullying. The focus of the policy is on both personal and shared responsibility.

     

    • Definitions and Illustrative Examples:
      • Examples of Prohibited Materials:
        1. Pornographic images or obscene images or text on Internet web sites.
        2. Material that contains abusive, profane, inflammatory, coercive, defamatory, blasphemous, or otherwise offensive language on web sites or in e-mail messages.
        3. Racist, exploitative, or illegal material or messages on web sites or in e-mail.
      • Examples of Prohibited Contacts:
        1. Responding to e-mail messages or solicitations (through advertisements or web postings) from unknown or unverified parties who seek to establish a youth’s identity and/or to communicate with the youth for any purpose.
        2. Initiating contact with unknown or unverified parties or parties seeking contact youth for any purposes.
      • Examples of Prohibited Use:
        1. Deliberately searching for and accessing prohibited materials.
        2. Creating and transmitting e-mail messages that contain unacceptable language or content such as that listed above in A and B under Examples of Prohibited Contacts.
        3. Creating and publishing Internet materials that contain unacceptable language and content.
      • Examples of Cyber-bullying:
        1. Cyber-bullying includes, but is not limited to, the following misuses of technology: harassing, teasing, intimidating, threatening, or terrorizing another individual by way of any technological tool, such as sending or posting inappropriate or derogatory email messages, instant messages, text messages, digital pictures or images, or website postings which has the effect of:
          1. Physically, emotionally or mentally harming an individual.
          2. Placing an individual in reasonable fear of physical, emotional or mental harm.
          3. Placing an individual in reasonable fear of damage to or loss of personal property; or
          4. Creating an intimidating or hostile environment that substantially interferes with an individual’s educational opportunities.
    • Unintentional Exposure of Youth to Prohibited Materials on the Internet

    It is Delta’s policy that Chapters must undertake every reasonable step to prevent exposure of youth participants to undesirable materials on the Internet. It is recognized that this can happen not only through the youth deliberately searching for such materials, but also unintentionally when a justifiable Internet search yields unexpected results. To prevent such occurrences the chapter shall adopt the following practices:

    • Chapters should use an Internet Provider or software that blocks access by:
      • Filtering sites by a grading process, and,
      • Filtering sites by language content and prohibit sites with unacceptable vocabulary.
    • Chapters must strictly supervise Internet usage:
      • Members must strictly supervise youth participant’s Internet activity, and there should be no searching of the Internet without a supervisor checking periodically during use and reviewing the sites accessed after a youth logs off.
      • Install appropriate language filtering software (e.g., Net Nanny).
    • Intentional Access of Prohibited Materials by Youth. Chapter shall explain clearly and firmly to the youth that they are prohibited from intentionally accessing prohibited material on the Internet. The youth also must be informed that if she/he violates this policy, she/he will be disciplined, and her/his parents or guardian will be notified. Chapters must follow through with disciplining the youth and notifying the parents or guardian.
    • Deliberate Access to Prohibited Materials by Adults. Adults are prohibited from deliberately accessing prohibited materials. Any adult who violates this policy will be terminated as a volunteer.
    • Receipt and transmission of e-mails by youth. It is recognized that, even with training and supervision, youth may receive or transmit e- mail messages that contain unacceptable (or even prohibited) language or content. It is also recognized that some people may try to use e-mail to identify and contact children for unacceptable reasons. To avoid these problems, Chapters should adopt the following practices:
      1. Use an Internet e-mail service that guarantees the bona-fide nature of e-mail communicants and that vets youth’s e-mail for undesirable content.
      2. Depending on the circumstances and the age or maturity of the youth, allow youth to read e-mail messages only when an adult is present or when the messages have been previewed by an adult.
      3. Take steps to verify the identity of anyone seeking to establish regular e-mail communications with youth.
      4. Allow youth to send e-mail messages only when the contents have been approved by an adult.
      5. If members or volunteers believe that youth have been targeted with e-mail messages by parties with criminal or inappropriate intent, immediately take the following steps: retain the messages; record the incident by completing the Risk Management Incident Report form; inform the youth’s parents; report the incident to law enforcement or other local or state authorities and report the incident to the Chapter president and the Regional Director.
    • Publishing Materials on the Internet. No materials, whether created by volunteers or youth participants, that contain any prohibited images, language, or content shall be published on the Internet. Infringement of this rule shall result in disciplinary action. No materials shall be published on the Internet that reveals the identity of any youth.
    • Use of Delta’s Internet by Visitors and Guests. No visitor or guest shall be allowed to use any Delta computer.
    • Intellectual Property Rights.
      Delta’s Intellectual Property. No individual member owns any of Delta’s intellectual property (which includes any
      1. Delta logo, word(s), or phrase(s) commonly associated with, and understood to refer to, Delta, and the “look” of any Mark used to distinguish merchandise and service as being associated with or related to Delta. Thus, no member is authorized to use such property for any inappropriate or any commercial purpose (i.e., to make money from using the property or to promote other causes), or to authorize any third party to use Delta’s intellectual property for any purpose. See Delta’s Code of Conduct, Social Media Guidelines, and Primer on the Use of the Intellectual Property of Delta Sigma Theta Sorority, Incorporated.
      2. Third Partiers” Intellectual Property Rights. All materials on the Internet are copyrighted and/or trademarked unless copyright has been expressly waived. Delta respects the intellectual property rights (copyright, trademarks, service marks, and related rights) of third-party owners Internet materials, and Delta assumes no liability for violations of any intellectual property rights by volunteers or youth participants.
    • Parental Approval of Publication of Photographs or Other Materials. 
      1. Chapters may publish photographs of youth participants on the Internet only if the parent or guardian has granted authorization. Depending on the nature and content, other materials may be published so long as the parent or guardian has given written consent. Delta must obtain the signed Photograph, Media, and Video Authorization Form from the Parents/Guardians of a youth before publishing any content that includes images of a youth participant.
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