Delta Sigma Theta Sorority, Incorporated

Norfolk Alumnae Chapter

Dr. Jeanne L. Noble Delta G.E.M.S

Growing and Empowering Myself Successfully

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Dear Parents/Guardian:

The women of the Norfolk Alumnae Chapter of Delta Sigma Theta Sorority, Inc. would like to extend an invitation to your daughter to participate in the Dr. Jeanne L. Noble Delta GEMS- one of the Sorority's National Programs. The Dr. Jeanne L. Noble Delta GEMS program is designed for adolescent girls aged 14-18 who have the desire and are interested in developing their leadership skills, express an interest in math, science, technology or careers that are considered non-traditional and who enjoy learning new things. Delta GEMS provide 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 to sharpen and enhance their skills to achieve high levels of academic success;

·  To assist girls in proper goal setting and planning for their futures high school and beyond; and

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

If you would like for your student to become a part of this rewarding experience, please complete the enclosed application package in its entirety. Please use the checklist below to ensure you have completed all required documents:

□  Student application

□  Parent agreement form

□  Consent to photograph form

□  Shirt promissory note

The deadline for all applications is September 28, 2014. If you have any questions, please contact Ms. Shayla Myrick 757-572-7740.

Ms. Shayla Myrick

Chair of Delta GEMS

Norfolk Alumnae Chapter of Delta Sigma Theta Sorority, Inc.

Dr. Jeanne Noble Institute of Delta GEMS Application

2014-2015

**PLEASE Print**

Please do not skip any questions. If it does not apply, please enter N/A on the line.

Name: ______

Address: ______

City: ______Zip: ______

Neighborhood: ______

Home #:______

Cell #:______(If GEM does not have a cell phone, please provide

guardian’s number)

Email Address: ______

Best means of communication (Please circle one): email cell phone home phone

Date of Birth: ______Age: ______

Emergency contact info:

Name: ______Relationship: ______

Telephone#:______Alternate #:______

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How did you hear about this program?

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List all extracurricular activities (including community and church activities)

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Are you employed? ______, If yes, how many hours per week do you work? _____

Delta GEMS will meet at least TWICE a month, is there anything that would prevent you from FULLY participating? ______

If yes, please explain______

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School: ______

Classification:

_____ Freshman

_____ Sophomore

_____ Junior

_____ Senior

Cumulative GPA: ______weakest subject______strongest subject______

Do you plan to attend college once you graduate? ______. If yes, which college/university ______Major______

What are your career goals? ______

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Why did you choose this career? ______

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What community service projects can the Delta GEMS do to promote social responsibility? ______

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What other types of activities would you like for the GEMS to participate in?

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OUR GOAL:

The goal of this program is to develop strong, confident and respectful young ladies and prepare you to take an active role in your success and our society

Now that you know our goal, please explain why you would like to participate in the program.

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**Reminder………………Did you answer ALL the questions????????

**Only completed applications will receive consideration**

Delta Sigma Theta Sorority, Inc.

Norfolk Almunae Chapter

Dr. Jeanne L. Noble Delta GEMS

Parent Agreement

By my signature below, I hereby verify that the above information is accurate. My signature grants permission for my child to participate in the Dr. Jeanne Noble Delta GEMS, field trips, monthly meetings, and activities therein. I will facilitate and support my child’s timely attendance and participation.

I agree not to hold the Norfolk Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or the Dr. Jeanne Noble Delta GEMS and its member responsible and/or liable for an injuries or illnesses that my child may sustain while in attendance at the sessions of the Delta GEMS. I also agree not to hold the above named organizations or its members or appointees individually, liable for the loss or destruction of my child’s property.

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Parent’s / Guardian’s Signature Date

APPLICANTS DO WRITE BELOW THIS LINE

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Date Application was
Received /
Method of Delivery / Other Information:

Delta Sigma Theta Sorority, Inc.

Norfolk Almunae Chapter

Dr. Jeanne L. Noble Delta GEMS

Consent to Photograph

I, ______give permission for my daughter, ______, to be photographed and videotaped. My signature gives consent to the use of her likeness in any publication, educational material, advertising, news media, and World Wide Web materials that the Delta Academy may utilize and produce.

I understand and agree that such materials, including all negative, positive, digital images and prints shall become and remain the sole property of the Dr. Jeanne Noble 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 Dr. Jeanne Noble GEMS Academy for potential future use. I agree to release the Dr. Jeanne Noble GEMS 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 parents upon request.

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Parent’s / Guardian’s Signature Date

Effective Date: September 1, 2014

Expiration Date: June 30, 2015

Delta Sigma Theta Sorority, Inc.

Norfolk Almunae Chapter

Dr. Jeanne L. Noble Delta GEMS

Shirt Promissory Note

I, ______borrowed a Delta GEMS shirt from the Norfolk Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated. As the borrower, I promise to return the shirt in good condition at the end of the program. Anytime that I decide to voluntarily leave, miss the allotted number of meetings, or graduate, I promise to return the shirt in good condition. If I fail to adhere to these rules, I will be responsible for paying the chapter a total of $13.00.

______Committee Chair Signature and Date Delta GEMS participant Signature and Date