Youth Salute Form

YOUTH SALUTE SUBMISSION FORM
Student Name (first, last)

First NameLast Name
Personal Email:
example@example.com
High School
Grade Level
Cumulative GPA (4.0 scale or 5.0 scale)
A copy of the student’s current report card must be scanned with this submission form via e-mail.

2025-2026 ACADEMIC Achievements:
2025-2026 EXTRACURRICULAR Activities:
2025-2026 COMMUNITY SERVICE Activities:
Goals and Future Plans:

COUNSELOR/SPONSOR/YOUTH LEADER INFORMATION
Name/Title

First NameLast Name
Title
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
PARENT/GUARDIAN INFORMATION
Name:

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Student:

First NameLast Name
I grant permission for my student to participate in the Youth Salute hosted by the El Paso Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated.

I authorize and consent to the use of my student’s name, image, and likeness in any publications, educational materials, promotional materials, advertising, news media, social media platforms, and website content produced or utilized by the El Paso Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated.

I understand and agree that all photographs, video recordings, digital images, prints, and related materials shall become and remain the sole property of the El Paso Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated., and that I will have no ownership rights or claims to such materials.

I further understand and agree that these materials may be maintained on file and used for future lawful purposes consistent with the mission of the organization.

I acknowledge that, as a parent/guardian, I may also appear in photographs or recordings if I participate in Youth Salute events.

I hereby release and hold harmless the El Paso Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated. from all claims, liabilities, or damages arising out of or related to the taking, use, publication, or distribution of such materials.

Copies of photographs may be provided to the parent/guardian upon request.
Signature of Parent/Guardian:
Date:

MonthDayYear
Date
Should be Empty:

YOUTH SALUTE SUBMISSION FORM