Deltas Building Brothers: Student/Guardian Registration Form

Deltas Building Brothers: Burlington & Beyond

Complete this interest form to register the young man in your care for participation in this brotherhood empowerment forum hosted by the Burlington Alumnae Chapter of Delta Sigma Theta Sorority, Inc. Taking place on Saturday, October 17, 2026, at Alamance Community College Auditorium, 1247 Jimmie Kerr Rd, Graham, NC 27253. This event connects middle and high school students with positive Black male role models for real conversations, mentorship, and growth. A parallel session, The Red Table, offers supportive dialogue for mothers and caregivers.
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade Level
Child's Age
Child's Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child Address

Street Address

Street Address Line 2
CityState / ProvinceZIP Code
How will your child be transported to the program?

Other
Parent/Guardian's Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email Address
example@example.com
Do you plan to stay for The Red Table intended for mothers and caregivers?
Medical Information

Health Information: Please check any current health conditions that may require attention during the program day.

Rows	Yes	No	Describe as Needed
Anemia
Asthma Inhaler Required?
Attention Deficit Hyperactivity Disorder
Diabetes
EpiPen Injections Required?
Food Allergies (If yes, please specify as light refreshments will be provided)
Hearing Loss (If yes, please specify if an ASL interpreter or hearing assistant is required)
Headaches or Migraines
Heart Disease
Mobility Issues (If yes, please specify)
Seizure Disorder (i.e., epilepsy)
Sensitivities (i.e., insect bites, latex, etc. If yes, please specify)
Vision Problems
Are there any other conditions or restrictions required? If yes, please specify.

Medications
List any daily or emergency medications the student takes, and indicate whether they will have them on-site (EpiPen, inhaler, etc.).
Medication Allergies
List any medication allergies we should be aware of.
Primary Emergency Contact

First & Last NameRelationship
Primary Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact (Optional)

First & Last NameRelationship
Secondary Emergency Contact (Optional) Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Liability & Participation Consent

I understand and agree to allow the young man in my care to participate in Deltas Building Brothers: Burlington & Beyond. I acknowledge that participation may involve light physical activity, movement between spaces, and engagement in group discussions. I release the Burlington Alumnae Chapter of Delta Sigma Theta Sorority, Inc., its volunteers, and event partners from any liability for accidental injury that may occur during the event, except in cases of gross negligence. I affirm that all medical information provided is accurate to the best of my knowledge and authorize emergency medical treatment if necessary.
Signature

Please sign to acknowledge the Liability & Participation Consent.
Within 48 hours of submitting this registration form, you will receive an email containing the following documents to review and sign electronically: participation waiver, photo and media release, youth code of conduct, and transportation form. We look forward to engaging with you and your student next month.
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Deltas Building Brothers: Burlington & Beyond

Medical Information