2026 - 2027 Program Application
EMBODI, presented by the Prince George’s County Alumnae Chapter of Delta Sigma Theta Sorority, Inc., in collaboration with the 100 Black Men of Prince George’s County, will meet on the third Saturday of each month, from October 17, 2026 through May 15, 2027.
Please complete the form in its entirety.
APPLICANT INFORMATION
Applicant Name
*
First Name
Last Name
Date of Birth
*
Current Age
*
School
*
Grade Level
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Most Recent Grade Point Average
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Youth Picture
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian 1:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
YOUTH INTERESTS & ACTIVITIES
Favorite School Subject(s)
*
List extracurricular activities (including school, community or church activities): Modeling, Volunteer, etc.
*
Hobbies/Talents:
*
What are your plans/goals after high school?
*
Have you ever participated in a mentoring program?
*
Please Select
Yes
No
If yes, please tell us the name of the mentoring program(s) in which you participated. If no, please insert "N/A."
*
List suggested topics that you would like to discuss during the 2026 - 2027 program year:
*
List activities or community service projects in which you would like to participate during the 2026 - 2027 program year:
*
YOUTH ESSAY - 150 - 200 WORDS
Please explain why you would like to participate in EMBODI. Your response might include the experiences, skills, or knowledge you hope to gain this year. Your essay should be between 150 and 200 words in length.
*
SUBMISSION INSTRUCTIONS & PROGRAM COMMITMENT
All applications must be completed, signed, and submitted no later than September 30, 2026. Important Note: If selected for the program, both the youth participant and a parent/guardian are required to attend the Kickoff/Orientation session (specific date to be announced). Notification of acceptance will be sent via email. By signing below, parent/guardian and youth confirm that all information provided is accurate to the best of their knowledge. Both the applicant and the parent/guardian must sign and date this application.
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: