Northharrisdeltas.org



-358774-385444 DELTA SIGMA THETA SORORITY, INC North Harris County Alumnae Chapter Delta AcademyStudent Application Form2019 - 2020(PLEASE PRINT)? Returning Participant ? New ParticipantStudent Name:__________________________________________________________________________DOB:__________________________________Age:_________Current Grade:_______________________Address:_______________________________________________________________________________City, State:______________________________________________________________________________School Name and District:_________________________________________________________________Educational Strengths:____________________________________________________________________Educational Challenges:__________________________________________________________________Talents/Skills/Hobbies:____________________________________________________________________Extra-Curricular Activities:________________________________________________________________Community Service Activities:______________________________________________________________What do you wish to gain from participating in the Dr. Betty Shabazz Delta Academy_________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________Participant Signature____________________________________Date______________________53816250-349249-285749 DELTA SIGMA THETA SORORITY, INC North Harris County Alumnae Chapter Delta AcademyParent/Guardian Form(PLEASE PRINT)Parent/Guardian Name:__________________________________________________________________Relationship to student:___________________________________________________________________Address:________________________________________________________________________________City, State:______________________________________________________________________________Zip Code:_______________________________________________________________________________Home phone:____________________________________________________________________________Work Phone:____________________________________________________________________________Cell Phone:______________________________________________________________________________E-Mail Address:__________________________________________________________________________Are you a member of Delta Sigma Theta Sorority, Inc.? ? Yes ? NoIf yes, please provide Chapter name: ___________________________________________________________Is a relative a member? ? Yes ? No If yes, Relationship: ________________________________________If active, please provide Chapter name: _________________________________________________________PARENT/LEGAL GUARDIAN VERIFICATION:By my signature, I hereby verify that the above information is current and accurate. I agree for my child to participate in the Dr. Betty Shabazz Delta Academy hosted by North Harris County Alumnae Chapter of Delta Sigma Theta Sorority, including field trips, and will facilitate and support my child’s regular and timely attendance and participation. I understand that the DBS Delta Academy hosted by North Harris County Alumnae Chapter will offer and implement programs which will be held within the chapter’s service areas (Cypress, Jersey Village, Spring, Tomball and Humble). By my signature, I hereby verify that the above information is accurate to the best of my knowledge and authorize appropriate actions in the case of an emergency in accordance with the information provided on this form. I further grant permission for my child to participant in all field trips/activities planned by the DBS Delta Academy. Furthermore, I understand that while participating in this group, my child’s picture and/or name may appear on videotape, the sorority’s/chapter’s website, newspaper, or television._____________________________________________________________Mail to:Delta Sigma Theta Sorority, Inc.North Harris County Alumnae Chapter 12320 Barker Cypress Rd Ste. 600 #229Cypress, TX 77429Or email completed form to:Ceceliab@ ................
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