2026-2027 BCAC DST YOUTH PARENT/GUARDIAN FORMS

Youth Program Year: 2026-2027

Please complete the application below. Complete all questions to the best of your ability. Your information will allow the Broward County Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated to meet our grant requirements.
Is the applicant new to BCAC's Delta’s youth programs or a returning participant?
Mentoring Programs
Additional Programs
Student Name

First NameMiddle NameLast NameSuffix
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Ethnicity:
Race

Other
Student Address

Street Address

Street Address Line 2

CityState

Zip Code
Student Phone Number

Area CodePhone Number
Student Email
example@example.com
School Name
Grade
1st Parent/Legal Guardian Name

PrefixFirst NameLast NameSuffix
Phone Number

Area CodePhone Number
Email
example@example.com
2nd Parent/Legal Guardian Name

PrefixFirst NameLast NameSuffix
Phone Number

Area CodePhone Number
Email
example@example.com
Household Income ( Please Select One)
Household Size
Number of Adults
Number of Children
Is any member of your household a military veteran?
Participant’s Commitment:
I agree to try my best to attend and fully participate in all scheduled sessions. I will have an open mind and will challenge myself to learn new things, meet new people, and have a positive attitude. I will abide by the Code of Conduct.
Signature
Parent’s/Guardian’s Commitment:
I give permission for my child/children to participate in sessions and events sponsored by the Broward County Alumnae Chapter of Delta Sigma Theta Sorority, Inc. I understand the rules of the programs and will be an active supporter of my child in this enrichment program. I will make every effort to help him/her attend all scheduled sessions.
Signature

APPENDIX B1

PARENTAL/GUARDIAN AFFIRMATION WAIVER AND RELEASE
I, Parent's Name* , Parent/Guardian, on behalf of Participant Minor Child* (“Participant Minor Child”) do hereby release, waive, discharge, covenant not to sue and agree to hold harmless Delta Sigma Theta Sorority, Incorporated (“Delta”), its officers, National Executive Board, employees, members, local Chapters, representatives, agents, affiliates, and assigns (collectively “Releases”), from any and all claims, demands, and actions of any and every kind directly or indirectly arising out of, or relating in any respect to Participant Minor Child’s participation in the Chapter’s Youth Initiative.

My waiver and release of all claims, demands, actions, and liability shall include, without limitation, any injury, illness, death, property damage or loss to the Participant Minor Child which may be caused by any act or failure to act, by the Releases, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of any Releases. I understand that, without limitation of the foregoing, neither Delta nor the Program shall be liable, and each is hereby released from all claims that may arise from loss or damage to the Participant Minor Child’s personal property.

As the Parent/Guardian, I hereby give my permission for my child to participate in the Chapter’s youth initiative (including planned activities), and I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation.
Signature
Relationship to Participant:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B2

PHOTOGRAPH, MEDIA, AND VIDEO AUTHORIZATION RELEASE FORM
I, Parent/Guardian Name* , on behalf ofParticipant Minor Child Name* give permission for the Broward County Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated 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.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B3

YOUTH CODE OF CONDUCT FOR IN‐PERSON MEETINGS
PARTICIPANT NAME

First NameLast Name
1. Respect all participants (other youth and adult volunteers) by not using foul, hurtful, or obscene language or engaging in physical violence, bullying (including cyber‐bullying), or other aggressive behaviors that threaten the safety of others.
2. Respect the property rights of others. This means do not damage or deface the building or property within the building where Chapter activities are held; do not damage or take the personal property of any other participant or volunteer; and do not use Delta’s name or any symbol or logo (Delta’s intellectual property) on any clothing, books, bags, or other items.
3. Return supplies to their proper place after using them.
4. Clean up all work areas properly.
5. Listen carefully to directions and when someone else is talking.
6. Respect designated quiet areas, such as a homework/reading area.
7. Stay within the program’s designated areas within the building.
8. Cooperate and participate in organized activities.
9. Assume full responsibility for all personal belongings. Please leave valuables at home.
10. Do not bring any weapons, cigarettes/drugs, alcohol, or anything illegal to any activity at any time.
Sanctions for Violating Code of Conduct

Bad Language/Abusive Teasing and Related Acts:
1st Time: Verbal warning, parent or guardian notified from this point forward
2nd Time: Loss of privileges
3rd Time: 1‐week suspension from program
4th Time: Next occurrence, the youth is removed from the program.

Physical Violence and Other Misconduct:
1st Time: Removal from situation, loss of privileges, guardian notified from this point forward
2nd Time: Next occurrence, the youth is removed from the program.

Illegal Substances or Dangerous Weapons
1st Time: Youth is removed from the program. If a youth is in possession of an illegal substance or dangerous weapon, the police will be notified as well.
(Student Participant)

With my parent or other adult, I have read the Code of Conduct and sanctions for violating the Code. I understand the Code and the sanctions. I will follow the Code of Conduct.
Student Participant Signature
Student Participant Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(Parent)

I have read and understand the Code of Conduct and sanctions for violating the Code of Conduct. I understand that my child’s compliance with the Code of Conduct is a condition of her/his participation in the Chapter’s youth program. I agree that the sanctions for violating the Code of Conduct are reasonable and will help my child comply.
Parent Participant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B4

YOUTH PICK‐UP AUTHORIZATION
I, Parent/Guardian Name authorize the persons listed below to pick‐up from the youth initiatives program. For my child’s safety, I understand that all authorized persons on the list below will be asked to show photo identification before my child is released to them; therefore, I will notify all authorized persons of this requirement so that they will have photo identification with them when they arrive to pick‐up my child. (Please include parents/ guardians names).
Name

First NameLast Name
Relationship
Home Phone
Work Phone
Cell Phone
- Name
  
  First NameLast Name
- Relationship
- Home Phone
- Work Phone
- Cell Phone
- Name
  
  First NameLast Name
- Relationship
- Home Phone
- Work Phone
- Cell Phone
- Name
  
  First NameLast Name
- Relationship
- Home Phone
- Work Phone
- Cell Phone
- Name
  
  First NameLast Name
- Relationship
- Home Phone
- Work Phone
- Cell Phone
- By signing below, I verify that I have read and agree to the Student Pick‐Up policies described above and authorize the Chapter to release my child to the persons listed above. I also agree tonotify the Chapter in writing of any changes to the above list of authorized persons.
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B6a

PARENT WAIVER AND PERMISSION FOR YOUTH TO BE TRANSPORTED BY TEENAGE DRIVER
ALL TEENAGE DRIVERS MUST HAVE A NON‐PROVISIONAL DRIVER’S LICENSE
Will your youth participant be riding with a teenage driver (under the age of 21) to or from any program activities?
Name of Child:

First NameMiddle NameLast NameSuffix
Teenage Driver Name:

First NameMiddle NameLast NameSuffix
Event:
Location:
(Note: If giving permission for driver to transport youth to all activities, please indicate “ALL” for Event/Location)
Participant Parent/Guardian Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Teenage Driver Parent/Guardian Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B6b

PARENT WAIVER AND PERMISSION FOR TEENAGE DRIVER TO TRANSPORT YOUTH
Will a teenage driver (under the age of 21) be transporting a youth participant to or from any activities?
ALL TEENAGE DRIVERS MUST HAVE A NON‐PROVISIONAL DRIVER’S LICENSE
Name of Child (being transported):

First NameLast Name
Event:
Location:
Teenage Driver:

First NameLast Name
(Note: If giving permission for driver to transport youth to all activities, please indicate “ALL” for Event/Location)
Teenage Driver Parent/Guardian Name:

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Teenage Driver Parent/Guardian Signature:

APPENDIX B7

OFF‐SITE PERMISSION
I, Parent/Guardian Name , as parent or legal guardian, give permission for Child's Name to participate in the Chapter’s Youth Initiatives Program’s (the “Initiatives”) activities taking place off site. I understand that transportation to and from these activities will be provided for my Child by the Chapter.

I understand that the field trips are part of the Initiatives and if I choose to not have my Child participate in one or more off‐site activities, I must make other care arrangements for my/our child during the times of that field trip activity.

I assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, except for gross negligence or intentional infliction of harm by the Initiatives, its officers, agents, or employees.

I do hereby agree to release and hold harmless the Initiatives, 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 for any damage, loss, or injury to my/our child or damage to my/our child’s property arising from my/our child’s participation in field trips, other than damage, loss, or injury that results from gross negligence or intentional infliction of harm by the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board, employees, members, representatives, agents and assigns.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B9

VIRTUAL MEETING/EVENT PARTICIPANT AGREEMENT
I, Parent/Guardian* (“Parent/Guardian”), as a parent or legal guardian of child* , give permission for Delta Sigma Theta Sorority, Incorporated (the Sorority) and the Broward County Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated (the Chapter), to host and facilitate closed virtual meetings/events using Zoom (“the Virtual Meeting Platform”), that my/our child will attend during participation in the Youth Initiative Program activities, without payment or any consideration and without notifying me in advance and hereby acknowledge, understand, and agree to the terms enumerated below, including the terms set forth on any Schedules attached hereto and incorporated by reference (the "Participant Agreement").
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

APPENDIX B10

PARENT/GUARDIAN ACKNOWLEDGEMENT OF INFORMATIONAL FORMS
The Parent/Guardian forms listed below are for informational purposes and do not require a signature.
By initialing the forms on the chart below, I acknowledge receipt of the form and that I have read and
understand the information provided.
Youth Participant Name:

First NameLast Name
Parent/Guardian Name:

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Acknowledgement

Rows	PARENT/GUARDIAN INITIALS
FORM B11- Confidentiality Policy
FORM B12- Youth Sign‐In/Sign‐Out Policy
FORM B13- Internet Youth Policy

Should be Empty:

Rows	Yes	No
Anemia
Asthma Inhaler required?
Attention Deficit Hyperactivity Disorder
Diabetes
EpiPen Injections required?
Food Allergies

Rows	Yes	No
Headaches or Migraines
Heart Disease
Mobility Issues

Rows	Yes	No
Seizure Disorder (i.e., epilepsy)
Sensitivities (i.e., insect bites)

Rows	Yes	No
Vision Problems
Contact lenses required?
Eyeglasses required?

Youth Program Year: 2026-2027

APPENDIX B1

APPENDIX B2

APPENDIX B3

(Student Participant)

(Parent)

APPENDIX B4

APPENDIX B6a

APPENDIX B6b

APPENDIX B7

APPENDIX B8

Health Information

EMERGENCY CONTACT

APPENDIX B9

APPENDIX B10