• Teen Summit Registration - Fall 2026

    Amplify Your Future: Dream. Decide. Do.

  • Student Registration Section

  • Who is completing this registration form?*
  • Is your student currently in a CCAC Youth Program (i.e. Cotillion, GEMS, EMBODI, Academy)*
  • Grade (Program Student)*
  • Grade*
  • Format: (000) 000-0000.
  • Does your student have any dietary restrictions?*
  • Does your student have any food or medical allergies?*
  • Does your student have prescribed medication as it relates to their allergy?
  • Please choose the first workshop you are interested in attending. Space will be limited, First Come, First Serve.*
  • Is there a topic you are passionate about learning more on and you selected it in the previous section?*

  • Emergency Contact Section

    Contact Information
  • Format: (000) 000-0000.

  • Parent Consent Section

  • CCAC takes photos and videos to capture memories. Do you consent to your child being photographed, recorded, or videotaped?*

  • Appendix B2

    Photograph, Media, and Video Authorization Release

  • I,   *   *   , Parent/Guardian, on behalf of   *   *   (“Participant Minor Child”), give permission for the local Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to publish on the Internet or 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 authorize the Chapter to publish or distribute these Images for the purpose of publicizing the Chapter’s programs, including the 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 the Parent/Guardian, and I am authorized legally to give this consent, and do hereby give my consent without reservation to the foregoing on behalf of my child.

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