Foothill Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
2016-2017 Application
Dr. Betty Shabazz Delta Academy & Dr. Jeanne L. Noble Delta GEMS
2 | Page
Foothill Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
2016-2017
Dr. Betty Shabazz Delta Academy
Dr. Jeanne L. Noble Delta GEMS
STUDENT INFORMATION
______
NAME: ______DATE:______
First Middle Last
ADDRESS: ______
Street Address Apt.
CITY: ______ZIP CODE: ______
HOME PHONE: ( )______CELL PHONE: ( )______
EMAIL ADDRESS: ______
DATE OF BIRTH: _____/______/___ AGE: ______T-SHIRT SIZE: ______
(mm) (dd) (yyyy)
PARENT’S/GUARDIAN’S NAME:
______
First M.I. Last
HOME PHONE: ( )______CELL PHONE: ( )______
EMAIL ADDRESS: ______
EMERGENCY CONTACT: ______
First M.I. Last
CONTACT NUMBER: ( )______ALT NUMBER: ( )______
EMAIL ADDRESS: ______
MEDICAL (To Be Completed By Parent/Guardian)
IS APPLICANT:
(1) UNDER A DOCTOR’S CARE AT THIS TIME? YES______NO ______
IF YES, DOCTOR’S NAME ______
DOCTOR’S PHONE NUMBER ______
(2) TAKING ANY MEDICATIONS? YES ______NO ______
IF YES, WHAT ARE YOU TAKING? ______
DOES APPLICANT HAVE ALLERGIES (food, dust, pollen, animals, drugs, etc.)?
YES ______NO ______
IF YES, LIST THEM ______
IS THERE ANY ACTIVITY THAT THE APPLICANT CANNOT PARTICIPATE IN?
YES______NO______
IF YES, PLEASE LIST: ______
EDUCATION: (To Be Completed By Applicant)
HAVE YOU PARTICIPATED IN Delta Academy/GEMS BEFORE? YES ____ NO ____
IF YES, EXCLUDING THIS YEAR HOW MANY YEARS HAVE YOU ATTENDED?____
SCHOOL: ______
GRADE: ______COUNSELOR: ______
MATH LEVEL/CLASS (i.e. Algebra I): ______
2015 - 2016 Final Grades: MATH: ______ENGLISH: ______
SCIENCE: ______HISTORY: ______
READING: ______
HAVE YOU PASSED THE CAHSEE (10TH grade and above only)? YES _____ NO _____
HAVE YOU TAKEN THE SAT OR ACT (9th-12th grade only)? Yes______NO______
LIST YOUR FAVORITE SCHOOL SUBJECTS: ______
______
LIST THE SCHOOL CLUBS AND TEAMS YOU BELONG TO: ______
LIST THE CLUBS AND ACTIVITIES YOU PARTICIPATE IN OUTSIDE OF SCHOOL:
______
LIST YOUR HOBBIES: ______
______
(Student Name)
has my permission to attend the Delta Academy/GEMS program. In case of an emergency, I give my permission to apply whatever lifesaving first aid is necessary until I can be reached.
______
PARENT/GUARDIAN’S SIGNATURE DATE
______
APPLICANT’S SIGNATURE DATE
APPLICATION DUE OCTOBER 1, 2016
PROGRAM ORIENTATION: SATURDAY, OCTOBER 15, 2016
**** A COPY OF APPLICANT’S 2015-2016 SCHOOL YEAR REPORT CARD MUST BE SUBMITTED AT THE FIRST MEETING.*** IF YOU HAVE ANY QUESTIONS, REGARDING THIS APPLICATION, PLEASE CONTACT: DIERDRE GAY @ (213) 718-4421 EMAIL:
Dr. Betty Shabazz Delta Academy & Dr. Jeanne L. Noble Delta GEMS rev. 8/22/15