2026 - 2027 Dr. Betty Shabazz Delta Academy Application

2026 - 2027 Dr. Betty Shabazz Delta Academy Application
Thank you for your interest in the Dr. Betty Shabazz Delta Academy youth enrichment program sponsored by the Pontiac Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated. Please complete this application in its entirety by September 11, 2026.
Participant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Birthday

MonthDayYear
What school will you be attending in the fall?
What grade will you be in this fall?
Parent / Guardian Information
Name

First NameLast Name
Relationship to Applicant
Phone Number
Format: (000) 000-0000.
Email
Parent / Guardian Information
Name

First NameLast Name
Relationship to Applicant
Phone Number
Format: (000) 000-0000.
Email
Additional Information
Who referred you to Delta Academy?
What extracurricular activities are you involved in (school, community, church)?
Why do you want to participate in the Dr. Betty Shabazz Delta Academy program?
Delta Academy Shirt Size
Acknowlegement Statement
I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. If accepted into the Delta Academy program both the parent/guardian and the youth participant must attend the Parent Youth Orientation on September 26, 2026 to continue with the program.
Parent / Guardian Signature
MonthDayYear
Date
Youth Signature
MonthDayYear
Should be Empty:

Participant Information