Delta g. E. M. S. (Growing and Empowering Myself Successfully) 2015-2016 program application



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DELTA G.E.M.S. (Growing and Empowering Myself Successfully)

2015-2016 PROGRAM APPLICATION
Thank you for your interest in the Delta G.E.M.S. (Growing and Empowering Myself Successfully) Program with Delta Sigma Theta Sorority, Inc. Suburban Houston Fort Bend Alumnae Chapter. A natural outgrowth and expansion for the continuation of the highly successful “Dr. Betty Shabaaz Delta Academy: Catching the Dreams of Tomorrow”, Delta Gems was created to “catch the dreams” of African American adolescent girls aged 14-18. Delta GEMS provides the frame work to actualize those dreams through the performance of specific tasks that develop a “CAN DO” attitude. The goals for Delta GEMS are:


  • To instill the need to excel academically;

  • To provide tools that enable girls to sharpen and enhance their skills to achieve high levels of academic success;

  • To create compassionate, caring, and community minded young women by actively involving them in service learning and community service opportunities.

Serving as a motivational tool targeting African American female teenagers, the primary objective for Delta G.E.M.S. is to increase knowledge and awareness of issues and concerns affecting women today. The Delta GEMS framework is composed of five major components (Scholarship, Sisterhood, Show Me the Money, Service, and Infinitely Complete). Topics within the five major components are designed to provide interactive lessons and activities that provide opportunities for self-reflection and individual growth.

Our sessions are scheduled to begin September 26, 2015; if your application is accepted to participate in this year’s program you will receive notification no later than August 30, 2015. Please complete the attached application and return to:


Email: dm2355@hotmail.com

Or

Mail:

Attn: Delta GEMS

Delta Sigma Theta Sorority, Inc.



P.O. Box 2066

Missouri City, TX 77459
No later than August 1, 2015

Should you have any questions in the interim, please do not hesitate to contact the Program Coordinators, Dr. Deborah McGinty at (713) 398-8255, dm2355@hotmail.com or Tasha Davison at (713) 471-2857, tashadavison@aol.com.


Again thank you for your interest.
Respectfully,
Silvia Tiller-Jackson, Esq. Chapter President

Suburban Houston – Fort Bend Alumnae Chapter


Dr. Deborah Myles, Sub-Committee Chair

Tasha Davison, Sub- Committee Co-chair



DELTA G.E.M.S. (Growing and Empowering Myself Successfully)

2015-2016 PROGRAM APPLICATION
Application must be filled out COMPLETELY and can be typewritten or printed clearly in black or blue ink. Please mail to address above no later than August 1, 2015. Incomplete applications will not be accepted.


Personal Information


Name:

Date of birth:

Phone (Home):

Phone (Cell):

Current address:

City:

State:

ZIP Code:

Email address (print clearly) :

If your address is in Houston, what is your geographic location:

(e.g. SW, NE)






Have you previously participated in Delta Academy or G.E.M.S.? No  Yes 

If yes, what year(s)?

Do you have any food allergies?

No  Yes 



If yes, please indicate:

T-shirt Size:



Parent or Guardian Information


Student lives with (select one): Both Parents  One Parent  Guardian 

Parent(s) or Guardian(s) Name:

Phone (can be work or cell) :

Best time to reach:

Current address:

City:

State:

ZIP Code:

Email address (print clearly) :

Emergency Contact


(1) Name of a relative not residing with you:

Relationship:

Phone:

(2) Name of a relative not residing with you:

Relationship:

Phone:








PLEASE MAKE SURE EMAIL ADDRESSES ARE CLEAR AND ACCURATE (FOR THE APPLICANT AND PARENT(S) OR GUARDIAN(S))

School Information


High School Name:

Grade:

GPA (for information purposes only):

High School Counselor Name:

School address:

City:

State:

ZIP Code:

Favorite subject(s):

Subject(s) in which I have the most problems:

Extra-curricular activities (indicate offices held, if applicable)




















Essay
On a separate sheet of paper, answer the essay question below. Please be sure to put it in typed essay format, and attach your response to the application. Your response should be no more than 200-300 words in length (no more than one page).
Describe one of the biggest challenges that you are currently facing and you feel your participation in Delta GEMS program will help you overcome it.

Signatures


I hereby state that the information on this application is true and complete. I also do hereby agree to make the necessary commitment to attend as well as participate in each scheduled session/activity.

Signature of applicant:

Date:

For questions or additional information, please contact Delta GEMS coordinators Dr. Deborah McGinty at (713) 398-8255, dm2355@hotmail.com or Tasha Davison at (713) 471-2857, tashadavison@aol.com.
Parental Consent Form

(To be completed and signed by parent/guardian)
Emergency Medical Information

In order to meet all legal requirements, I hereby authorize the members of the Suburban Houston-Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc. to give consent for my daughter to receive any and all emergency medical care at my expense. In the event that I cannot be reached to make emergency medical care arrangements at the time of illness or accident, I hereby authorize the emergency contact persons listed below to take my daughter to the nearest hospital or medical facility. In the event they are also not available, I then authorize the members of the Suburban Houston-Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc. to take my daughter to the nearest hospital or medical facility.


Parental Affirmation

I, ___________________________________, Parent/Guardian, under penalty of

perjury, do hereby affirm to the Suburban Houston- Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated that I authorize the participation of ________________________,

(Participant Minor Child), in the Delta G.E.M.S youth initiatives program

(including planned activities), and that I have the legal authority to provide my consent

and authorization for such participation.


Printed name of Parent/Legal Guardian: _____________________________________________
Signature of Parent/Legal Guardian: Date: ____________
Waiver and Release

I, _______________________________________, (Parent/Guardian), on behalf of

___________________________________ (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, Suburban Houston - Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc., representatives, agents, affiliates, and assigns (collectively “Releasees”), 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 Delta G.E.M.S. Program.

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 Releasees, unless

such injury, illness, death, property damage or loss is a direct result of the willful

misconduct of any Releasee. 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.



Printed name of Parent/Legal Guardian: _____________________________________________
Signature of Parent/Legal Guardian: Date: ____________


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