Delta Sigma Theta Sorority, Inc. Jacksonville Alumnae Chapter

Delta Sigma Theta Sorority, Inc.
Jacksonville Alumnae Chapter
Dear Parent/Guardian:
The Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc. invites you to join
our 2015-2016 Empowering Males to Build Opportunities for Developing Independence
Program (EMBODI) where participants ages 13 to 17, will participate in activities,
community service and educational workshops. Participants are required to attend
meetings from September 2015 through May 2016. We are excited about the program,
and have planned a wonderful experience for the young males who participate.
The goals of EMBODI are:
To expand the horizons of young African American males by cultivating a
personal vision for their lives.
To provide tools for participants to attain a higher quality of life.
To provide participants with an awareness of various college and career
options to make rewarding life choices and decisions.
To create community-minded participants by actively involving them in
service learning and community service opportunities.
If you would like your son to become a part of this rewarding experience, please
complete the enclosed application packet in its entirety. Please return your completed
application packet via mail to Delta Sigma Theta Sorority, Inc. PO Box 2435,
Jacksonville, FL 32203 or email at DSTJAXEMBODI@gmail.com.
During each program day, participants will be asked to stow away cell phones to
encourage and solicit active participation. In the event of an emergency, please contact
me via cell phone. I will ensure any pertinent information is communicated with your
youth upon making contact.
Further information will be discussed at the EMBODI participant orientation and kick-off
meeting on Saturday, September 19th, 2015 from 10:00am to 12:00pm. Parents/guardians
must be in attendance for this kick-off meeting. If you have any questions, please feel
free to contact Mo Gebre-Michael at 303-332-1035 (DSTJAXEMBODI@gmail.com).
Sincerely,
Mo Gebre-Michael
EMBODI Chair
Veronica Tutt
JAC President
Delta Sigma Theta Sorority, Inc

PO Box 2435
Jacksonville, FL 32203
EMBODI APPLICATION
Please Print
Students Information
Name (LAST, Middle Initial, FIRST)
Date of Birth
T-shirt Size
Address
City/State
Zip Code
Home Telephone (
Mobile Telephone (
Student E-mail Address
Family/Contact Information
Cell Phone: (
)
Work Phone: (
)
Parent/Legal Guardian Name
Parent Email
Address (if different from above)

Please indicate your preferred method of contact
Phone Call (
)
Text messages (
Parent/Legal Guardian Name
)
Email (
Cell Phone: (
)
Work Phone: (
)
)
Parent Email
Address (if different from above )

Name of Health Insurance
Policy Holder Name
Physician
Phone Number (
Policy #
)
Emergency Contact Name #1
Telephone#: (
Relationship to Student
Emergency Contact Name #2
Telephone#: (
Relationship to Student
Authorization Information
Please list all adults, other than Parent/Legal Guardian, authorized to sign the participant in and out of program days
or other events sponsored by the Jacksonville Alumnae Chapter.
Name
Relationship to Applicant
Address
Email Address
Home Phone Number
Cell Phone Number
Other Number
Name
Address
Email Address
Home Phone Number
Name
Cell Phone Number
Other Number
Address
Email Address
Home Phone Number
Cell Phone Number
Other Number
Parental/Legal Guardian Release:

I hereby release Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc., and the Grand Chapter of Delta Sigma Theta Sorority,
Inc., of any and all liability relating to any physical injury or accidents which may occur as a result of my childs direct or indirect
participation in activities or events conducted under the supervision and direction of Delta Sigma Theta Sorority, Incorporated.
In the event reasonable attempts to reach me are unsuccessful, I hereby give my consent for emergency medical or dental treatment to
be administered to my child. Furthermore, I agree to release Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc., and the
Grand Chapter of Delta Sigma Theta Sorority, Inc., from any and all liability associated with the emergency care and treatment of my
child.
I give permission for my child to be a part of the Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc.,
EMBODI program. I understand all the rules and regulations of the program, and agree to abide by them.
I promise to be an active participant/supporter of my child in this enrichment program.
Parent/Guardian Signature:
X
Parent/Guardian Signature:
X
Date:
Date:

STUDENT APPLICATION FORM
2015 - 2016
Date: ______________________________________________
Student Name: ______________________________________________
Name of Parent/Primary Guardian: ______________________________________________
DOB: ____________ Age: ____________ Current Grade: ___________________
Home Phone: ____________________________________________
Cell Phone: ______________________________________________
E-mail address: __________________________________________
School Name: (Please give FULL name) __________________________________________________
Favorite School Subjects: _____________________________________________________________
Extra-Curricular Activities: _______________________________________________ ____________
Hobbies: _____________________________________________________________________________
What are your Talents (What do you do best and/or most like to do)?
______________________________________________________________________________________
What do you want to gain from participating in the EMBODI Program?

______________________________________________________________________________________
What new subjects would you like to learn about?
______________________________________________________________________________________
______________________________________________
(Student Signature and Date)

PROGRAM LIABILITY WAIVER FORM
This signed agreement officially absolves the Jacksonville Alumnae Chapter of Delta
Sigma Theta Sorority, Inc. and the Grand Chapter of Delta Sigma Theta Sorority, Inc. of
any and all liability from any accidents or injuries resulting from your or your childs
participation in any activity or event.
Furthermore, it is understood that any and all medical expenses incurred due to injuries
sustained at any activity or event organized by the Jacksonville Alumnae Chapter of
Delta Sigma Theta Sorority, Inc. is the sole responsibility of the participant in the activity
or event and if a minor, the parent or guardian. This is inclusive of pre-existing
conditions, which may become aggravated due to your or your childs participation in
any activity or event.
It is also understood that no legal action will be brought against Jacksonville Alumnae
Chapter of Delta Sigma Theta Sorority, Inc. or subsidiaries or authorized personnel by
you or your child because of any matter directly or indirectly related to your and your
childs participation in any activity or event held by the Jacksonville Alumnae Chapter of
Parent/Guardians Authorization (PLEASE PRINT)
As a parent/guardian of (childs name) _________________________, I request he
attend EMBODI, and take part in all activities and events. I hereby give my consent to
any field trip my son may take while attending EMBODI. In case of emergency the
committee leader, sub-leader or their representative has my permission to give minor first
aid or take my child to an emergency treatment facility.
I, (parent/guardian), _________________________ further request the committee leader,
sub-leader or their representative to call a physician for medical care for my child,
_________________________, should an emergency arise. I understand that the
program staff will make a conscientious effort to locate me via the telephone number(s)
provided
at
registration
as
well
as
attempting
to
contact
me
at_________________________, before any action is taken but if it is not possible to
locate me, I understand that I will accept all medical expenses.
By signing your name, you are stating that you have read and fully understand and are in
agreement with this waiver.
(Signature of Parent)
(Date)

PHOTOGRAPH WAIVER
I, the parent/guardian of (print participants name) _________________________
consent to the release of photographs, videos, audio and other related recorded materials
captured during the programs activities. Such materials shall remain the sole property of
EMBODI and shall not be sold to any entity.
BY MY SIGNATURE, I AM INDICATING THAT I HAVE READ AND
UNDERSTAND THE FOREGOING INFORMATION.
______________________________________________________________________________________
(Signature of Participant)
(Date)
______________________________________________________________________________________
(Signature of Parent)
(Date)

EMBODI PARENT CONSENT FORM
Parent/Guardian Name: __________________________________________________________
Student Name: __________________________________________________________________
Relationship: ________________________________________
Please list any allergies (foods and/or drugs)
Please list any illnesses, medications, medical conditions (i.e. diabetes) or physical limitations
that the EMBODI committee members should be aware of:
_____________________________________________________________________________________
______________________________________________________________________________________
By my signature below, I hereby verify that the above information is accurate. My signature
grants permission for my child to participate in the Empowering Males to Build Opportunities for
Developing Independence (EMBODI) Program, field trips, and activities therein. In giving my
permission to participate, I understand that he will take part in scheduled meetings, workshops,
cultural, educational and recreational programs. I agree to provide transportation for my child to
all scheduled meetings and activities. I also agree to facilitate and support my childs timely
attendance and participation.
I agree not to hold the Jacksonville Alumnae Chapter of Delta Sigma Theta Sorority, Inc. or the
EMBODI Program and its members responsible and/or liable for any injuries or illnesses that my
child may sustain while in attendance at the sessions of the EMBODI Program. I also agree not
to hold the above named organization, or its members or appointees individually, liable for the
loss or destruction of my child's property.
________________________________________________________
(Parent/Guardian Signature)
_________
(Date)

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