Winston Salem Alumnae Chapter

Delta Sigma Theta Sorority, Incorporated

Winston Salem Alumnae Chapter

Dr. Betty Shabazz Delta Academy

“Catching the Dreams of Tomorrow,

Preparing Girls for Success in the 21st Century”

______

Dear Parents/Guardian:

The women of the Winston Salem Alumnae Chapter of Delta Sigma Theta Sorority, Inc. would like to extend an invitation to your daughter to participate in the Dr. Betty Shabazz Delta Academy – one of the Sorority’s National Programs. The Dr. Betty Shabazz Delta Academy is designed for young ladies 11-14 years of age 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. The Dr. Betty Shabazz Delta Academy is named for the outstanding and accomplished widow of Malcolm X. In addition to being a registered nurse, Dr. Shabazz earned her doctorate degree in higher education administration and curriculum development. The Shabazz Delta Academy activities address math, science, technology, time management, non-traditional careers, self-esteem, etiquette, Women and African American History, community service activities and literacy through a book club.

If you would like for your daughter to become a part of this rewarding experience, please complete the enclosed application package in its entirety (student application, parent consent to photograph, and student health history) and mail to the address below no later than

October 3, 2014. If you have any questions, please contact Ms. Kendra Scott, Committee Chair, or (336) 406-3402.

Sincerely,

Elizabeth Newton, President, Winston-Salem Alumnae Chapter

Delta Sigma Theta Sorority, Inc.

P.O. Box 20483

Winston Salem, NC 27120-0483

For information only: This is not a program of Winston-Salem/Forsyth County Schools. It is not endorsed or supported by the school system.
Delta Sigma Theta Sorority, Inc.

Winston Salem Alumnae Chapter
Catching the Dreams of Tomorrow,

Preparing Girls for Success in the 21st Century”

Dr. Betty Shabazz Delta Academy

2014-2015 Application for Participation

PLEASE PRINT NEATLY or TYPE

Application must be REVIEWED and SIGNED by a parent or legal guardian.

Name:______

Date of Birth: ______Age as of 09/01/14 _____

month date year

Address: ______

City ______State ______ZIP ______

Applicant’s Cell Phone Number (if applicable) ______

Applicant’s E-Mail: ______

School: ______Grade: ______

Favorite School Subjects:______

Extra-Curricular Activities______

______

Hobbies:______

Your Talents (What you do best and/or most like to do):

______

Tee Shirt Size: ______

What career occupation would you like to pursue ? ______

What other job fields are you interested in?______

______

What type of workshop sessions or classes, do you think would be helpful to you as a teenager? ______

______

Please check the workshops / activities you would be interested in attending and/participating in.

___ Etiquette ___ Time Management/organizing

___ Live Plays & Musicals ___ Study Habits & Homework Tips

___ Public Speaking ___ Real Life Budgeting

___ Career Fairs ___ Volunteering

___ Tutoring ___ Technology

___ Nutrition & Exercise ___ Health and Beauty

___ Self Esteem ___ Book Club

___ Math and Science Exploration

Which school subjects do you need help with most? ______Math ______Science

What new subject would you like to learn about?______

______

What leadership skills do you possess ? (ex. good communicator, well organized, dependable, etc.)

______

What would you like to gain from being a participant of Delta Academy?

______

______

______

______

Based on the purpose and goals of Delta Academy, write a short statement explaining why you should be selected as a Delta Academy participant.

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If you are selected to participate in Delta Academy, how do you plan to manage your responsibilities with academy and the other organizations you are involved in? ______

______

______

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Student Signature and Date

Delta Sigma Theta Sorority, Inc.

Winston Salem Alumnae Chapter
Dr. Betty Shabazz Delta Academy

Parent Consent Form

2014-2015

Name of Parent or

Legal Guardian: ______

Relationship:______

Address:______

City, State, Zip Code:______

Home Number: ______Work Number: ______

Parent’s/Guardian’s Cell Phone Number: ______

Parent’s/Guardian’s E-Mail: ______

Emergency Contact #1 Name:______

Relationship: ______Phone Number: ______

Emergency Contact #2 Name: ______

Relationship: ______Phone Number: ______

Delta Sigma Theta Inc. Connection:

Are you a member of Delta Sigma Theta Sorority, Inc.? _____Yes _____No

If active, please provide Chapter Name:______

Is a relative a member? _____Yes _____No If yes, relationship:

______

If active, please provide Chapter name:______

By my signature below, I herby verify that the above information is accurate. My signature grants permission for my child to participate in the Dr. Betty Shabazz Delta Academy, monthly meetings, and activities therein. I will facilitate and support my child’s timely attendance and participation.

I agree not to hold the Winston Salem Alumnae Chapter of Delta Sigma Theta Sorority, Inc. and its members responsible and/or liable for an injuries or illnesses that my child may sustain while in attendance at the sessions of the Delta Academy. 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

------

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

Delta Sigma Theta Sorority, Inc.

Winston Salem Alumnae Chapter
Dr. Betty Shabazz Delta Academy

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. Betty Shabazz 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 Dr. Betty Shabazz Academy for potential future use. I agree to release the Dr. Betty Shabazz 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.

______

Parent’s / Guardian’s Signature Date

Effective Date: September 19, 2014

Expiration Date: May 16, 2015

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