Dr. Betty Shabazz Delta Academy Program

Dr. Betty Shabazz Delta Academy Program
“Catching the Dreams of Tomorrow, Preparing Young Women for the 21st Century”
HATTIESBURG ALUMNAE CHAPTER
DELTA SIGMA THETA SORORITY, INCORPORATED
www.deltasigmatheta.org
www.hattiesburgdst.org
Dear Parent(s) and Applicant:
Delta Sigma Theta Sorority, Inc. is an international public service organization committed to the
principles of sisterhood, scholarship and service. Locally, the Hattiesburg Alumnae Chapter
provides an array of public service programs including scholarships for eligible high school
seniors, support for Habitat for Humanity, community awareness of health care disparities,
voter registration drives, and the Dr. Betty Shabazz Delta Academy.
Thank you for your interest in becoming a member of Dr. Betty Shabazz Delta Academy
Program. Delta Academy is one of our sorority’s National Youth Initiative programs sponsored
by Hattiesburg Alumnae Chapter, serving girls ages 11-14. Our mission is to enable young girls
to develop an interest in Science, Math, and Technology. We also strive to foster a sense of
community service and build self-esteem in each member.
Please see the attached guidelines and membership application necessary for completion
regarding membership in Delta Academy. The completed application packet must be RECEIVED
by mail on Friday, October 3, 2014. Please return this application packet to:
Delta Sigma Theta Sorority, Inc.
Hattiesburg Alumnae Chapter
Post Office Box 17347
Hattiesburg MS 39404-7347
ATTN: Delta Academy, Monét Ducksworth
If you have any questions or concerns, you may contact the Committee Chair, Monét
Ducksworth at [email protected]
A complete application packet includes the following: the attached application, a copy of birth
certificate, copy of last report card, Recommendation form, and a picture of the applicant.
Please place the packet in a large clasp envelope and mail to the address listed above by the
deadline. Note: Parental permission for participation is required for membership. Also, the
documents submitted will not be returned to any applicant and incomplete packets will not be
accepted.
Tawnya Holliman, President
Hattiesburg Alumnae Chapter
Dr. Betty Shabazz Delta Academy program focuses on the following:
1. Developing interests in math, science, and computer technology
2. Exposing young ladies to non-traditional careers in the areas listed in #1
3. Providing exposure to public service involvement
4. Encouraging educational and cultural enrichment
5. Helping to achieve academic excellence
6. Heightening social graces
7. Stressing the importance of proper health
8. Emphasizing the dangers of drug usage
9. Developing leadership skills and building self-esteem
10. Promoting healthy relationships with peers and Delta members
Membership Guidelines:
•
•
•
•
•
•
•
•
•
Female ages 11-14
One must exemplify good conduct
Maintain a minimal of a C-average in all classes
Submit a copy of report card no later than two weeks of school’s distribution
Attendance/promptness of all Delta Academy meetings/activities (no more than 2
unexcused absents)
No pregnancies and/or applicants with children
No dual membership in another Greek sponsored organization
If accepted, parents will be responsible for some activity fees and cost
Parents will be responsible for transporting and picking up the member in a timely
manner
****Guidelines will be strictly enforced (no exceptions)****
Requirements for application review:
1.
2.
3.
4.
5.
6.
Complete application (must be signed)
Copy of last report card
Recommendation letter from a core teacher, principal, and/or counselor
Copy of birth certificate to verify age (copy only)
Photograph of the applicant
Completed application packet must be received by Friday, October 3, 2014.
Signature of Applicant: ________________________________________ Date: ___________
Signature of Parent: ___________________________________________ Date: ___________
DR. BETTY SHABAZZ DELTA ACADEMY PROGRAM
“Catching the Dreams of Tomorrow, Preparing Young Women for the 21st Century”
APPLICATION
DATE ____________________
Name: _______________________________________________________
DOB: _____________ Age: _________ Grade: __________
Address: __________________________________________________________
City, State, Zip code: ________________________________________________
Telephone: (Home) ________________ Cell (if applicable) ______________
E-mail address, if applicable: ____________________________________
School Name: (Please give FULL name) ____________________________________
Address: _____________________________________________________
Favorite School Subject(s): _____________________________________________
__________________________________________________________________
Extra-Curricular Activities and Hobbies:
__________________________________________________________________
__________________________________________________________________
What would like to achieve from participating in Delta Academy?
__________________________________________________________________
__________________________________________________________________
Talent(s) (singing, dancing, drawing, public speaking, sports etc)
______________________________________________________________________________
________________________________________________________
Church Affiliation: (if applicable) ___________________________________________
__________________________________________________________________
Future Goal(s): _____________________________________________________
How did you find out about Dr. Betty Shabazz Delta Academy Program?
PARENTAL/LEGAL GUARDIAN INFORMATION
Name: _______________________________________Relationship: __________
Address: _____________________________________________________
City, State, Zip Code: __________________________________________
Telephones: Home______________ Work: ______________ Cell ___________
Emergency Contact:
Name: ____________________________________
Contact Number ___________________________
Name:___________________________________
Contact Number ___________________________
Name:___________________________________
Contact Number ___________________________
Parent Information Only:
Are you a member of Delta Sigma Theta Sorority, Inc.? ___Yes
_____No
If yes, please provide chapter name: ______________________________
Is a relative a member? _____Yes _____No
If yes, specify the relationship ________________
If active, please provide chapter name: _____________________________
Candidates T-Shirt Size:
Please Circle: Adult or Youth
XS S M L XL OTHER__________
Parental Permission and Waiver Form
I, ___________________________________, hereby authorize the Hattiesburg
(Parent Name)
Alumnae Chapter, Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta
Academy) to photograph or film my child,______________________________,
(Child Name)
and consent to the use of her likeness in any all publications, educational materials, research,
advertising, news media and World Wide Web materials.
I understand and agree that such materials, including all negatives, positives, digital images and
prints shall become and remain the sole property of the Hattiesburg Alumnae Chapter of Delta
Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) and I shall have no right or title to
such items. I further understand and agree that these materials may be kept on file and used by
the Hattiesburg Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta
Academy) for potential future purposes and further agree to release the Hattiesburg Alumnae
Chapter of Delta Sigma Theta Sorority, Inc. (Dr. Betty Shabazz Delta Academy) from any and all
liability arising from or in connection with the taking, use, publication, or dissemination of such
materials. Copies of these photos may be distributed to the parent upon request.
I agree not to hold the Dr. Betty Shabazz Delta Academy or its affiliates, specifically the
Hattiesburg Alumnae Chapter, or its members or appointees individually responsible and/or
liable for an injuries or illnesses that my child may sustain while in attendance at the sessions of
the Dr. Betty Shabazz Delta Academy. I also agree not to hold the organizations or field trip
sites, or its members or appointees individually, liable for the loss or destruction of my child's
property.
I understand that my child is responsible for taking her medication at the required intervals and
that the Dr. Betty Shabazz Delta Academy assumes no responsibility for administering the
medication, including over-the-counter medication, to my child. In the case of an emergency,
the Dr. Betty Shabazz Delta Academy has my permission to allow treatment by an emergency
medical technician, or nurse, doctor, or health care professional and to allow transportation to
a local hospital, unless I notify the Dr. Betty Shabazz Delta Academy officials otherwise in
writing.
I understand reasonable efforts will be made to supervise my child. I, and my child understand
that certain conduct on the part of my child will not be tolerated, such as: unacceptable sexual
conduct, unacceptable dress, violent speech or conduct, and the use of controlled substances
or alcohol, and that the commission of any of these acts will result in my child's immediate
dismissal from the program. I understand that in the event that one of these acts occurs, the
Dr. Betty Shabazz Delta Academy will contact via telephone at the number listed for the parent
or the emergency contact person. I agree that when I or the emergency contact person is
called, I or the emergency contact person will immediately come and pick my child up from the
session or healthy facility.
PARENT/LEGAL GUARDIAN VERIFICATION FORM
By my signature, I hereby verify that the above information is current and accurate. I agree to
allow my child to participate in the Dr. Betty Shabazz Delta Academy Program. This includes
field trips and supporting my child’s regular attendance and participation.
Participant Signature: ______________________________________Date:_______________
Parent Signature:__________________________________________Date:________________
**Remember: Completion of this application and attendance does not guarantee
membership. All packets will be thoroughly reviewed. Limited slots are available.
Thank you for your interest in Dr. Betty Shabazz Delta Academy Program.
DR. BETTY SHABAZZ DELTA ACEDEMY
PROGRAM
Student Performance Review
This form is to be completed by a school official such as a teacher, counselor, and/or principal
STUDENT INFORMATION
Name
Subject
School
Date
Grade
Teacher
Review Period
to
RATINGS
1 = Poor
Student Conduct
Comments
Student Work
Performance
Comments
Attendance/Punctuality
Comments
Initiative
Comments
Communication/Listening Skills
Comments
Dependability
Comments
Overall Rating (average the rating numbers above)
EVALUATION
ADDITIONAL COMMENTS
GOALS
(as agreed upon by
student and teacher)
2 = Fair
3 = Satisfactory
4 = Good
5 = Excellent
STUDENT INFORMATION
Name
Subject
School
Date
Grade
Teacher
Review Period
to
VERIFICATION OF REVIEW
By signing this form, you confirm that you have discussed this review in detail with your teacher. Signing this form does not necessarily
indicate that you agree with this evaluation.
Student Signature
Date
Teacher Signature
Date