2019 - 2020
Youth Programs Application
Delta Academy, Delta GEMS, EMBODI
Memphis Alumnae Chapter
Delta Sigma Theta Sorority Inc.
In order for this application to be considered all required information must be entered fully.
• Student Information
• Parent Information
• Emergency Contact Information
• Media Release Consent
Parent/Guardian Residence Information
Media Release Form
I/We, as parent(s) or legal guardian(s) of, give permission for the Memphis Alumnae 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/We also give permission for the Chapter to highlight my child’s achievements andactivities 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/We understand and agree that these Images will become the property of the Chapter, which shall have complete ownership of the Images. I hereby irrevocably authorized the Chapter to publish or distribute these Images for the purpose of publicizing the Chapter’s programs, including the Delta Academy/ Delta GEMS/ EMBODI 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/We 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/we hereby certify that I/we are the parents/guardians of , authorized legally to give this consent, and do hereby give my/our consent without reservation to the foregoing on behalf of my/our child.