Youth Programs Application 2026-2027

Delta Academy ~ Delta GEMS ~ EMBODI

Delta Sigma Theta Sorority Incorporated, Potomac Valley Alumnae Chapter “PVAC” is committed to public service and addressing the needs of young people in our community. We invite you to apply for one of our 2025-2026 Youth Initiative Programs. The programs include:

EMBODI (Empowering Males to Build Opportunities for Developing Independence)

Studies show that educational institutions don’t provide the support needed by boys of color aged 11-18 to reach their fullest potential. EMBODI addresses the issues most pressing to this demographic through dialogue and recommendations for change and action. Areas EMBODI addresses include:

STEM Education	Culture	Self-efficacy
Leadership	Physical and Mental Health	Healthy Lifestyle Choices
Character	Ethics	Relationships
College Readiness	Fiscal Management	Civic Engagement
Service Learning

Dr. Betty Shabazz Delta Academy

The primary goal of Delta Academy is to prepare young girls for full participation as leaders in the 21st Century. The programming provides females (ages 11-14) with educational enrichment, augmenting what they receive in school. It focuses on academic achievement, leadership development, service learning, self-esteem, exposure to STEM and the arts, and preparing them for future success.

Delta GEMS (Growing & Empowering Myself Successfully):

Delta GEMS helps girls aged 14-18 develop a CAN DO attitude by providing a framework to actualize their dreams. Delta GEMS goals include:

Instilling a desire for academic excellence by enabling participants to sharpen their skills and achieve high levels of academic success.
Assisting participants with setting goals and planning for their lives in high school and beyond.
Creating compassionate, caring, and community-minded young women by participating in service learning and community service opportunities

Application Requirements
The application takes approximately 15 minutes to complete. Applicants must provide a list of their 2026-2027 out-of-school commitments (i.e. work, cheer, sports practice and games, honors club, Girl Scouts, choir rehearsal, etc.) and special events (i.e. Prom, Winter/Spring Break, Graduation, etc.) with their application. The application must be completed in its entirety and signed with original signatures. Submit the application to Delta Sigma Theta Sorority, Inc., PVAC, no later than August 23, 2026. NO EXCEPTIONS!

Acceptance in the PVAC’s 2026-2027 Youth Initiative Programs does not guarantee acceptance into any other PVAC community program, award, activity, and/or scholarship.

Contact Information
For questions or concerns, please contact either:

Daphne Page-Reaves, Chapter President
- 301-332-6888
- president@dstpvac.org
Annie Foster Ahmed, Second Vice President & Chair, Program Planning & Development
- 240-478-7938
- svp@dstpvac.org
Cheryl Vault, Carla Calhoun, & Judy Taylor, Bria Ware, Youth Initiative Chairs
- youthprograms@dstpvac.org

2026-2027 PVAC Youth Programs Schedule

3rd Saturday of every Month (September - June)

10:00 am - 12:00 pm

Meeting Location:

Stewartown Community Center

9310 Merust Lane, Gaithersburg, MD 20879

Workshop Topic	Date
Welcome & Introduction to Youth Programs	September 19, 2026
Financial Fortitude Workshop	October 17, 2026
College Preparation & Study Skills Workshop	November 21, 2026
Literacy & Fine Arts Workshop	December 19, 2026
International Awareness Workshop	January 16, 2027
Physical & Mental Health Workshop	February 20, 2027
Social Action Workshop	March 20, 2027
Social Interaction Workshop	April 17, 2027
STEAM Workshop	May 22, 2027*
End of Year Activity	June 2027 (TBD)

PARTICIPANT MINOR CHILD INFORMATION
PARTICIPANT MINOR CHILD FULL NAME
First Name & Last Name
PARTICIPANT MINOR CHILD FULL NAME

First NameLast Name
PARTICIPANT PREFERRED PRONOUNS
IS PARTICIPANT MINOR CHILD A CURRENT RESIDENT AND/OR CUSTOMER OF HOUSING OPPORTUNITIES COMMISSION (HOC)?
ADDRESS
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARTICIPANT MINOR CHILD DATE OF BIRTH

MonthDayYear
Date
CURRENT AGE
NAME OF SCHOOL ATTENDING FOR THE 2026-2027 SCHOOL YEAR
GRADE LEVEL FOR THE 2026-2027 SCHOOL YEAR
PARTICIPANT MINOR CHILD PICTURE

Cancelof
List any 2026-2027 out-of-school commitments (such as work, cheer, sports practice, honors club, girls scouts, choir rehearsal, etc) and special events (such as Prom, Winter/Spring Break, Graduation, etc.).

NAME OF PARENT/GUARDIAN #1
RELATIONSHIP TO PARTICIPANT
EMAIL
example@example.com
FULL ADDRESS (include city, state & zip code)
Include City, State and Zip Code
PARENT/GUARDIAN #1 CELL PHONE
(cell)Format: (000) 000-0000.
PARENT/GUARDIAN #1 HOME PHONE
(home)Format: (000) 000-0000.
PREFERRED METHOD OF COMMUNICATION
IS THERE ANOTHER PARENT/GUARDIAN NAME YOU WOULD LIKE TO INCLUDE?
NAME OF PARENT/GUARDIAN #2
RELATIONSHIP TO PARTICIPANT
FULL ADDRESS (include city, state & zip code) (if same as Parent #1, indicate "SAME" below)
Include city, state & zip code
PARENT/GUARDIAN #2 EMAIL
example@example.com
PARENT/GUARDIAN #2 CELL PHONE
(cell)Format: (000) 000-0000.
PARENT/GUARDIAN #2 HOME PHONE (if same as Parent #1 indicate "SAME" below)
(home)Format: (000) 000-0000.
PREFERRED METHOD OF COMMUNICATION

PARENT/GUARDIAN INFORMATION
PHOTO, VIDEO, MEDIA AUTHORIZATION
Do you give your permission for PVAC to use any photos taken of your child during their participation for the purpose of promoting/highlighting the activities of PVAC Youth Initiative Programs?
PARENT/GUARDIAN SIGNATURE
If not providing permission, please indicate "NO AUTHORIZATION" below
Date

MonthDayYear
Date

YOUTH PICK‐UP AUTHORIZATION

List the persons authorized to pick up your student from the youth programs.
Name 1
Relationship
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Add another pick-up person?
Name 2
Relationship
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Add another pick-up person?
Name 3
Relationship
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Add another pick-up person?
Name 4
Relationship
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Add another pick-up person?
Name 5
Relationship
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.

TRANSPORTATION INFORMATION

Indicate who will transport your student to the youth programs activities.
Is the person who will drive your student to the Youth Programs activities an ADULT or TEENAGER? ***Note: All teenage drivers must have a non-provisional driver's license. A waiver is required from the parent of the participant (e.g. the rider) and also the parent of the teenage driver
If giving permission for the adult driver to transport youth to ALL activities, please indicate "ALL" below
ADULT DRIVER
PARTICIPANT PARENT/GUARDIAN SIGNATURE
DATE

MonthDayYear
Date
If giving permission for the teenage driver to transport youth to ALL activities, please indicate "ALL" below
TEENAGE DRIVER
PARTICIPANT PARENT/GUARDIAN SIGNATURE
TEENAGE DRIVER PARENT/GUARDIAN NAME
TEENAGE DRIVER PARENT/GUARDIAN SIGNATURE
DATE

MonthDayYear
Date

EMERGENCY CONTACTS
If for any reason the Parent(s)/Guardian(s) cannot be reached, please contact the following person(s) who I/we hereby authorize to seek emergency medical or surgical care for my/our child.
NAME #1
FULL ADDRESS (include city, state & zip code)
Include city, state & zip code
CELL PHONE
(cell)Format: (000) 000-0000.
HOME PHONE
(home)Format: (000) 000-0000.
NAME #2
FULL ADDRESS (include city, state & zip code)
Include city, state & zip code
CELL PHONE
(cell)Format: (000) 000-0000.
HOME PHONE
(home)Format: (000) 000-0000.

REQUIRED SIGNATURES & REVIEW
The parent(s)/guardian(s) and the participant must sign the application. Preview the application before submitting to ensure the information provided is correct. You will also be able to download a copy on the preview page before submitting.
PARENT/GUARDIAN #1 INITIALS
PARENT/GUARDIAN #1 SIGNATURE
PARENT/GUARDIAN #2 SIGNATURE
Date

MonthDayYear
Date
PARTICIPANT MINOR CHILD SIGNATURE
Date

MonthDayYear
Date
Should be Empty:

Youth Programs Application 2026-2027

2026-2027 PVAC Youth Programs Schedule

3rd Saturday of every Month (September - June)

10:00 am - 12:00 pm

Meeting Location:

Stewartown Community Center

9310 Merust Lane, Gaithersburg, MD 20879

PARTICIPANT MINOR CHILD INFORMATION

PARENT/GUARDIAN INFORMATION

PHOTO, VIDEO, MEDIA AUTHORIZATION

YOUTH PICK‐UP AUTHORIZATION

TRANSPORTATION INFORMATION

MEDICAL AND EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACTS

If for any reason the Parent(s)/Guardian(s) cannot be reached, please contact the following person(s) who I/we hereby authorize to seek emergency medical or surgical care for my/our child.

REQUIRED SIGNATURES & REVIEW