2014 - 2015
DELTA GEMS INSITUTE APPLICATION
“DEVELOPING EFFECTIVE LEADERSHIP THROUGH GEMS (GROWING AND
EMPOWERING MYSELF SUCCESSFULLY)”
SPONSERED BY:
Sacramento Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
INTRODUCTION
Dr. Jeanne L. Noble
Delta Sigma Theta Sorority, Inc.
12th National President
The Delta GEMS program honors the 12th National President of Delta Sigma Theta Sorority, Inc., Dr.
Jeanne L. Noble. Dr. Noble was a legendary pioneer in the field of education. The Delta GEMS
Program, officially renamed The Dr. Jeanne L. Noble Delta GEMS Institute, continues to spotlight
teenage girls between the ages of 14-18 in grades 9 through 12. As National President of Delta Sigma
Theta Sorority, Inc., Dr. Noble‘s administration focused on campus sorors who were involved on the
front lines by sitting in and freedom riding. Civil rights issues were a high priority during her two terms in
office. Dr. Noble believed young women had to be supported emotionally, psychologically, spiritually
and financially. The sorority supported young women such as Soros Charlene Hunter and Vivian
Malone and other young people who took a stand on desegregating southern colleges and
universities. The need for solidarity and sisterhood was prevalent at the end of Soror Noble‘s
administration coinciding with the historic MARCH ON WASHINGTON on August 28, 1963.
Soror Noble was an exemplary role model for her sisters, serving by appointment on United States
Commissions from President‘s Kennedy, Johnson, and Nixon. In her report to the convention, Sorer
Noble reminded members that Deltas have a responsibility to lift as we climb and that elitism has no
place in the Delta House.
In many ways and on many fronts, Delta‘s commitment to accelerated activity in the area of public
service and program planning and development had been tested in what Soror Noble called the
crucible of social action. Dr. Noble stressed the need for women to become increasingly less social
and more social action oriented. The success of the Dr. Betty Shaba Delta Academy, one of the
sorority‘s signature programs created in 1996 out of an urgent sense that bold action was needed to
save our young females (ages 11-14) from the perils of academic failure, low self-esteem, and
crippled futures, gave incite to creating a new program that expanded the sorority‘s service to
young women.
The Delta GEMS Institute is a continuum of services that address the needs of young African
American women in grades 9 through 12 with a framework for the participants to discover and
understand their individual brilliance by embracing the AIMS of the GEMS theme “Growing and
Empowering Myself successfully”.
The goals for DELTA GEMS are:
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To promote positive social interactions
To develop effective written and oral communication skills
To encourage self-confidence, self-motivation, and self-discipline
To foster meaningful public service; including mentoring and networking
To strive for intellectual enrichment
To assist with the exploration of various career paths and means for obtaining
them (college and/or vocational skills training)
To support talents in academics, technology, sports, and fine arts
To maintain moral values and personal pride while experiencing the crossroads
of life
The mission of the DELTA GEMS Committee is to provide young ladies with a firm
structural program that will enhance their self-esteem, academic achievement,
leadership skills, and cultural awareness. This, in turn, will provide them with the
opportunity to develop emotionally, socially, intellectually and be prepared to take an
active role in their success as they face the challenges of the world.
The goals and objectives of the DELTA GEMS Committee will be accomplished through
a series of workshops and community service activities using the following frame work:
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Scholarship (Academic Excellence)
Sisterhood (Self Esteem, Health Awareness & Leadership)
“Showing Me the Money” (Financial Awareness)
Service (Social Responsibility Obtained through Community Service)
Infinitely Complete (The Rites of Passage)
The DELTA GEMS logo is likened to a gemologist who can see, through the use of
certain tools, the hidden treasure in unpolished jewels. DELTA GEMS uses the polished
jewels as a symbol of the facets that shine and glow within our young AfricanAmerican women.
2014-2015 GEMS Institute
October 11, 2014: Welcome and Orientation
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Introductions
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Ice-Breakers
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Application review
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Review expectations of family and participants
 Questions and Answers
November 8, 2014: Interview Prep/College Prep Workshop/College
Experience
December 13, 2014: Entrepreneurship
January 10, 2015: Leadership Development through Service Advocacy
February 14, 2015: Loving Yourself: Self-Awareness/Self-Image
March 2015: Youth State
April 11, 2015: Community Service
May 9, 2015: Healthy Lifestyles
June 13, 2015: End-Of-Year Program
PARENTAL AFFIRMATION
I, ___________________________________, Parent/Guardian, under penalty of
perjury, do hereby affirm to the Sacramento Alumnae Chapter of Delta Sigma Theta
Sorority, Incorporated that I authorize the participation of ________________________,
Participant Minor Child, in the Delta GEMS Institute youth initiative program(including
planned activities), and that I have the legal authority to provide my consent and
authorization for such participation.
Printed Name: ____________________________________
Signature: _______________________________________
Date: ___________________________________________
Relationship to child: ______________________________
WAIVER AND RELEASE
I, _______________________________________, Parent/Guardian, on behalf of
___________________________________ (“Participant Minor Child”) do hereby
release, waive, discharge, covenant not to sue and agree to hold harmless Delta
Sigma Theta Sorority, Incorporated (“Delta”), its officers, National Executive Board,
employees, members, local chapters, representatives, agents, affiliates, and assigns
(collectively “Releases”), from any and all claims, demands, and actions of any and
every kind directly or indirectly arising out of, or relating in any respect to Participant
Minor Child’s participation in the Delta GEMS Institute Program. My waiver and release
of all claims, demands, actions, and liability shall include without limitation, any injury,
illness, death, property damage or loss to the Participant Minor Child which may be
caused by any act, or failure to act, by the Releases, unless such injury, illness, death,
property damage or loss is a direct result of the willful misconduct of any Release.
I understand that, without limitation of the foregoing, neither Delta, nor the
Program, shall be liable and each is hereby released from all claims that may arise
from loss or damage to the Participant Minor Child’s personal property.
_____________________________________________
Parent/Guardian Signature
_________________________
Date
DR. JEANNE L. NOBLE GEMS INSTITUTE
Guidelines
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It is expected that GEMS attend all monthly sessions and complete homework
assignments.
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Please provide via telephone, e-mail or text message to the appropriate GEMS staff
(Veronica 916- 475-8986, Ericka Dennis 916-230-9603 or
sacramentodeltagems@gmail.com) twenty-four (24) hour notice of all absences.
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Cell phone usage is prohibited during workshops and/or fieldtrips unless for
emergencies.
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Please drop-off GEMS by 10:00 a.m. and pick-up at 1:00 p.m. Parent/Legal guardian
must sign your daughter in and out on the attendance sheet per session.
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Transportation costs associated with all fieldtrips and on/off-site workshops will be the
responsibility of the participant's parents/guardians.
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Encourage to provide your daughter with a snack per monthly sessions.
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All prescribed medications must have prescription label from pharmacy.
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Delta GEMS Institute application packet must be completed and returned by the
following meeting of first attendance
CODE OF CONDUCT FOR YOUTH
PARTICIPATING IN YOUTH INITIATIVES PROGRAM
1. Respect all participants (other youths and adult volunteers) by not using foul, hurtful
or obscene language or engaging in physical violence, bullying (including cyberbullying) or other aggressive behaviors that threaten the safety of others.
2. Respect the property rights of other. This means do not damage or deface the
building or property within the building where GEMS activities are held; do not
damage or take the personal property of any other participant or volunteer; and
do not use Delta’s name or any symbol or logo (Delta’s intellectual property) on
any clothing, books, bags, or other items.
3. Return supplies to their proper place after using them.
4. Clean up all work areas properly.
5. Listen carefully to directions and when someone else is talking.
6. Respect designated quiet areas, such as homework/reading area.
7. Stay within the program’s designated areas within the building.
8. Cooperate and participate in organized activities.
9. Assume full responsibility for all personal belongings. Please leave valuables at
home.
10. Do not bring any weapons, cigarettes/drugs, alcohol, or anything illegal to any
activity at any time.
Sanctions for Violating Code of Conduct
Bad Language/Abusive Teasing and Related Acts:
1st Time: Verbal warning, parent or guardian notified from this point forward
2nd Time: Loss of privileges
3rd Time: 1-day suspension from program
4th Time: 1-week suspension from program
Next occurrence youth is removed from the program.
Physical Violence and Other Misconduct:
1st Time: Removal from situation, loss of privileges, guardian notified from this point
forward
2nd Time: 1-day suspension from program
3rd Time: 1-week suspension from program
Next occurrence youth is removed from the program.
Illegal Substances or Dangerous Weapons:
1st Time: Youth is removed from the program. If a youth is in possession of an illegal
substance or dangerous weapon, the police will be notified as well.
With my parent or other adult, I have read the Code of Conduct and sanctions for
violating the Code. I understand the Code and the sanctions. I will follow the Code of
Conduct.
**************
I have read and understand the Code of Conduct and sanctions for violating the
Code of Conduct. I understand that my child’s compliance with the Code of Conduct
is a condition of her/his participation in the Delta GEMS Institute program. I agree that
the sanctions for violating the Code of Conduct are reasonable and will help my child
comply.
__________________________________
Print Name
__________________________________
Date
______________________________
Signature
YOUTH PICK-UP AUTHORIZATION FORM
I authorize the persons listed below to pick-up my child from the Delta GEMS Institute
youth initiatives program. For my child’s safety, I understand that all authorized persons
on the list below will be asked to show photo identification before my child is released
to them; therefore, I will notify all authorized persons of this requirement so that they will
have photo identification with them when they arrive to pick-up my child. (Please
include names of either parents or guardians on list below).
Name _________________________________________ Relationship_____________________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
Name _________________________________________ Relationship_____________________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
Name _________________________________________ Relationship_____________________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
Name _________________________________________ Relationship_____________________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
Name _________________________________________ Relationship_____________________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
By signing below, I verify that I have read and agree to the Student Pick-Up policies
described above and authorize the Sacramento Alumnae Chapter to release my
child to the persons listed above. I also agree to notify the Sacramento Alumnae
Chapter in writing of any changes to the above list of authorized persons.
Mother/Guardian Signature ___________________________________Date _______________
Father/Guardian Signature ____________________________________Date _______________
MEDICAL INFORMATION FORM
Today's Date: _________________________
Health History:
Child’s Name (Last, First, M.I.): _____________________________________________________
Gender (check one): Male_____ Female______ DOB (mm/dd/yy): __________________
Parent/Guardian Name: _________________________________________________________
Does Parent/Guardian live in home with child? __________________________
Parent/Guardian Name: __________________________________________________________
Does Parent/Guardian live at home with child? __________________________
Is/Has child been under regular supervision of a physician? _________________________
Name and address of physician___________________________________________________
Date of last physical exam: ____________________________
Health and Developmental History:
Childhood illness: Check any that apply
_ Measles _ Mumps _ Asthma _ Chickenpox _ Rheumatic Fever _ Hay Fever _ Diabetes
_ Epilepsy _ Whooping Cough _ Poliomyelitis _ Ten-Day Measles (Rubella) _ Three-Day
Measles (Rubella)
Other (please list): _________________________________________________________________
Does child have any significant health history, conditions, communicable illness, or
restrictions that may affect child’s participation in the Delta GEMS Institute youth
initiatives program? (check one) _ None _ Yes
If yes, please provide detailed explanation ________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does child have any significant food/medication/environmental allergies that may
require emergency medical care at the Delta GEMS Institute youth initiatives
program?
(check one) _ None __ Yes
If yes, please provide detailed explanation_______________________________________
________________________________________________________________________________
________________________________________________________________________________
Specify any other serious or severe illnesses or accidents: _________________________
________________________________________________________________________________
Does child take prescribed medications? _______________
Name the medications: _________________________________________________________
1)
2)
Frequency Taken: _______________________________________________________________
For any medications or treatment required during the course of the Delta GEMS
Institute youth initiatives program, a Medication Authorization Form should be
completed and submitted with this form.
Does child take any over the counter medications frequently? _______________
Name the medications: _________________________________________________________
Frequency Taken: ______________________________________________________________
Does child have any allergies? _________________
Specify: ________________________________________________________________________
Does the student use any special device(s) (i.e. hearing aids, cochlear implants, etc.):
____________?
Name the Device(s): ____________________________________________________________
Reason for use: _________________________________________________________________
EMERGENCY MEDICAL TREATMENT AUTHORIZATION
Name of Minor: ________________________________________________________________
Date of Birth___________________________________ Age ____________________________
Address: _______________________________________________________________________
City/State/Zip Code ____________________________________________________________
Parent/Guardian Home Phone __________________________________________________
Cell Phone_____________________ E-mail Address__________________________________
Minor’s Gender _________________Height ________________ Weight _________________
HEALTH INFORMATION
Below please check any current health condition that may require attention during
the Program day.
_ Allergies/Sensitivities (be specific)
Foods_________________________________________________________________________
Medicines_____________________________________________________________________
Bee sting or insect bite_________________________________________________________
Other_________________________________________________________________________
_ Asthma _ Inhaler required at Program
_ Vision Problems _ Glasses _ Contacts
_ Hearing Problems _ Hearing Aid(s)
_ ADD/ADHD
_ Other________________________________________________________________________
List all medications and dosages your child receives on a continual basis: _________
________________________________________________________________________________
PHYSICIAN & INSURANCE INFORMATION
Name of Child’s Physician___________________________________ Phone_______________
Health Insurance Company___________________________________ Phone______________
Policy Number ___________________________ Group Number _________________________
Insurance Company Address_______________________________________________________
City/State/Zip Code_______________________________________________________________
Name of Policy Holder_____________________________________________________________
Name of Policy Holder’s Employer _________________________________________________
EMERGENCY CONTACT INFORMATION
Name________________________________________________Relationship______________
Street Address__________________________________________________________________
City___________________________ State ______________Zip Code ____________________
Home Phone_______________ Work Phone __________________Cell Phone ___________
E-mail address__________________________________________________________________
Parent/Guardian #2
Name________________________________________________Relationship______________
Street Address__________________________________________________________________
City___________________________ State ______________Zip Code ____________________
Home Phone_______________ Work Phone __________________Cell Phone ___________
E-mail address__________________________________________________________________
If for any reason I/we cannot be reached, please contact the following person(s)
whom I/we hereby authorize to seek emergency medical or surgical care for my/our
child.
Name: _____________________________________ Relationship to Student _______________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
Name: ____________________________________ Relationship to Student _______________
Home Phone_____________ Work Phone ______________ Cell Phone __________________
In the event that the Program is unable to reach any of the individuals named above
promptly by phone, I/we authorize the Program to seek and secure any emergency
medical or surgical care for my/our child. I/We will be responsible for any and all
expenses incurred and authorize the medical facility at which treatment is rendered to
release all necessary information to my/our insurance company.
Parent/Guardian Signature _______________________________________Date_____________
Parent/Guardian Signature _______________________________________Date ____________
PHOTO RELEASE
I grant permission for the Sacramento Alumnae Chapter of Delta Sigma Theta Sorority,
Inc. to include my daughter in pictures taken at DELTA GEMS activities held throughout
the year. I also give permission for the Sacramento Alumnae Chapter of Delta Sigma
Theta Sorority, Inc. to use the pictures when explaining the purpose and objectives of
DELTA GEMS to the community.
Parent / Guardian Signature__________________________________________Date_________________
PARENT CONSENT FORM 2014-2015
Parent/Guardian Name:
________________________________________________________________________
Relationship: _____________________________
Address: _______________________________________________________________
City, State and Zip Code:
_______________________ ________________________________________________
Home Phone :(____) ________________________
Work Phone: (____) ________________________
Cell Phone: (____) _________________________
E-Mail Address: ________________________________________________________
How did you learn about the Delta GEMS Institute?
________________________________________________________________________
________________________________________________________________________
Are you a member of Delta Sigma Theta Sorority, Inc.?
Yes
No
If active, please provide Chapter name:
________________________________________________________________________
Do you have relative who is a member of Delta Sigma Theta Sorority, Inc.?
If yes, relationship: ______________________________________________________
If relative is active, please provide Chapter name:
________________________________________________________________________
Yes
No
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 L. Noble GEMS Institute, field trips and activities therein. I will facilitate
and support my child’s timely attendance and participation. I further agree to assume
the transportation costs for all fieldtrips and off-site workshop/activities.
I agree not to hold the Sacramento Alumnae Chapter of Delta Sigma Theta Sorority,
Inc. or the Dr. Jeanne L. Noble GEMS Institute 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 Dr. Jeanne L. Noble GEMS Institute. 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.
____________________________________________________________________________
Parent/Guardian Signature and Date
DR. JEANNE L. NOBLE GEMS INSTITUTE
STUDENT APPLICATION FORM 2014-2015
Date: _____________________
Student Name: ________________________________________________________
DOB: _____________________ Age: ________ Current Grade: ________
Address: _____________________________________________________________
City, State: ___________________________________________________________
Zip Code: _________________________________
Home Phone: (____) ________________________
Cell Phone: (____) __________________________
E-mail address: _______________________________________________________
School Name: (Please give FULL name)
_____________________________________________________________________
City, State and Zip Code:
_____________________________________________________________________
Please list your school involvement including sports, clubs, committees, etc.:
Please list your community involvement:
What are your interests?
What are your current and future goals in high school and beyond?
What would you hope to gain from being a part of the Delta GEMS Program?
Describe a fun activity for the Delta GEMS to do which will promote unity within the
group.
Describe one community service project the Delta GEMS can participate in, please
explain why you would like to do this community service project and how you and the
other GEMS could start this project. (A suggestion… thinks of something missing in YOUR
community).
Design one fundraising activity to help fund a community service project as well as
other Delta GEMS activities (i.e. field trips).
Who referred you to the Delta GEMS program?