Suburban Houston-Fort Bend Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
P.O. Box 2066
Missouri City, TX 77459
EMBODI
Empowering Males to Build Opportunities for Developing Independence
2012-2013PROGRAM APPLICATION
T
hank you for your interest in the EMBODI (Empowering Males to Build Opportunities for Developing Independence) Program with the Suburban Houston – Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc. The program is designed to refocus the efforts of the Sorority, with the support and action of other major organizations, on the plight of African-American males.
Both informal and empirical data suggests that the vast majority of African-American males continue to be in crisis and are not reaching their fullest potential - educationally, socially and emotionally. EMBODI is designed to address these issues through dialogue, and recommendations for change and action. The SHFBA program is unique in that it uses a peer mentoring model to help challenge young men to make better life decisions.
Our sessions this year will be held on the following dates and will be hosted at Houston Community College (10041 Cash Road Stafford, Texas 77477.) All meetings will begin at 11 am unless otherwise noted.
- Saturday, October 27th- Opening Session/Parent Orientation/Health Awareness
- Saturday, November 17th- Conflict Resolution/ Building Relationships
- Saturday, December 15th – Community Service Project-TBD
- Saturday, February 23rd- Men In Black (The Amazing Race)- First Colony Mall
- Saturday, March 16th- “March Madness”
- Saturday, April 6th- Community Service Project-Briargate Elementary
- May Week-TBD
Please complete your application and turn it in by October 6th, 2012 bymail or you may fax it using the information below.
Suburban Houston-Fort Bend Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
P.O. Box 2066
Missouri City, TX 77459
Or
Fax: (866) 748-5759
The deadline to turn in applications is Saturday, October 6th. If your application is accepted, you will receive notification by either phone call or email by Wednesday,October 17th,2012at the latest. Should you have any questions, please do not hesitate to contact the EMBODI Program Coordinators, Cherese King at (713) 256-2936 or ndTangela Jefferson at (832)715-9662 or .
Again, thank you for your interest!
Respectfully,
Sylvia Tiller, Chapter President
Suburban Houston - Fort Bend Alumnae Chapter 2012-2013
Cherese King, EMBODICoordinator
Tangela Jefferson, EMBODI Co-Coordinator
EMBODI
Empowering Males to Build Opportunities for Developing Independence
Application must be filled out COMPLETELY and can be typewritten or printed clearly in black or blue ink. Please mail to turn in no later than Saturday, October 6th. Incomplete applications will not be accepted.
Personal Information
Name:Date of birth: / Phone (Home): / Phone (Cell):
Current address:
City: / State: / ZIP Code:
Email address(print clearly):
If your address is in Houston, what is your geographic location:
(e.g. SW, NE)
Have you previously participated in EMBODI? No Yes / If yes, what year(s)?
Do you have any food allergies?
No Yes / If yes, please indicate:
T-shirt Size:
Parent or Guardian Information
Student lives with (select one): Both Parents One Parent GuardianParent(s) or Guardian(s) Name:
Phone (can be work or cell) : / Best time to reach:
Current address:
City: / State: / ZIP Code:
Email address(print clearly):
Emergency Contact
(1) Name of a relative not residing with you:Relationship: / Phone:
(2) Name of a relative not residing with you:
Relationship: / Phone:
PLEASE MAKE SURE EMAIL ADDRESSES ARE CLEAR AND ACCURATE FOR BOTH THE APPLICANT AND THE PARENT(S) OR GUARDIAN(S).
School Information
School Name:Grade: / GPA(for information purposes only): / School Counselor Name:
School address:
City: / State: / ZIP Code:
Favorite subject(s):
Subject(s) in which I have the most problems:
Extra-curricular activities (indicate offices held, if applicable)
EssayOn a separate sheet of paper, answer the essay question below. Please TYPE and attach your essay to the application. Your response should be no more than 200-300 words in length (no more than one page).
Describe one of the biggest challenges that you are currently facing and how you feel your participation in the EMBODI program will help you overcome it.
Signatures
I hereby state that the information on this application is true and complete. I also do hereby agree to make the necessary commitment to attend as well as participate in each scheduled session/activity.Signature of applicant: / Date:
For questions or additional information, please contact the EMBODI coordiantorsCherese King at (713) 256-2936 or and Tangela Jefferson at (832)715-9662 or .
Parental Consent Form
(To be completed and signed by parent/guardian)
Emergency Medical Information
In order to meet all legal requirements, I hereby authorize the members of the Suburban Houston-Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc. to give consent for my son to receive any and all emergency medical care at my expense. In the event that I cannot be reached to make emergency medical care arrangements at the time of illness or accident, I hereby authorize the emergency contact persons listed below to take my son to the nearest hospital or medical facility. In the event they are also not available, I then authorize the members of the Suburban Houston-Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc. to take my son to the nearest hospital or medical facility.
Parental Affirmation
I, ______, Parent/Guardian, under penalty ofperjury, do hereby affirm to the Suburban Houston - Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated that I authorize the participation of ______,(Participant Minor Child), in the EMBODI program(including planned activities), and that I have the legal authority to provide my consentand authorization for such participation.
Printed name of Parent/Legal Guardian: ______
Signature of Parent/Legal Guardian:______
Date: ______
Waiver and Release
I, ______, (Parent/Guardian), on behalf of
______(Participant Minor Child) do herebyrelease, waive, discharge, covenant not to sue and agree to hold harmless Delta SigmaTheta Sorority, Incorporated (“Delta”), its officers, National Executive Board,employees, members, Suburban Houston - Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc., members, officers representatives, agents, affiliates, and assigns(collectively “Releasees”), from any and all claims, demands, and actions of any andevery kind directly or indirectly arising out of, or relating in any respect to ParticipantMinor Child’s participation in the EMBODI Program.
My waiver and release of all claims, demands, actions, and liability shall includewithout limitation, any injury, illness, death, property damage or loss to the ParticipantMinor Child which may be caused by any act, or failure to act, by the Releasees, unlesssuch injury, illness, death, property damage or loss is a direct result of the willfulmisconduct of any Releasee.I understand that, without limitation of the foregoing, neither Delta, nor theProgram, shall be liable and each is hereby released from all claims that may arise fromloss or damage to the Participant Minor Child’s personal property.
I further understand that the program is sponsored by a local chapter of Delta Sigma Theta Sorority Inc., a national sorority and the Participant Minor Child may be filmed, videotaped or digitally reproduced by the sorority. Thus, I hereby sign my signature below to release, acquit, waive and forever discharge Delta Sigma Theta Sorority Inc., Suburban Houston – Fort Bend Alumnae Chapter of Delta Sigma Theta Sorority, Inc., its Board members, officers, assigns and individual members from all, and all manner of action(s), cause(es) of action that may arise forloss of property, personalinjury or use of likeness arising out of Participant Minor Child’s participationin the EMBODI program.
Printed name of Parent/Legal Guardian: ______
Signature of Parent/Legal Guardian:______
Date: ______
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