Delta Academy Delta GEMS EMBODI

(Girls ages 11-14) (Girls ages 14-18) (Boys ages 13-17)

Name of Student:

Address:

City/Zip: Phone:

Student Email Address:

Parent/Guardian Contact Information

Parent/Guardian Name:

Home Phone: Cell Phone:

Alternate Phone:

Email Address:

School Information

Name of Middle/High School:

Grade Level: Semester/Cumulative GPA:

Counselor’s Name:

Student Responses

Career Interests:

Extra-Curricular Activities:

Please indicate whether a family member is currently a member of DCP Alumnae Chapter:

ESSAY

(100-250 words)

Describe how you may benefit from the program.

Student Testament: I affirm that all statements made in this application are true. I understand that participation in the program requires a strong level of commitment and responsibility.

Student Applicant E-Signature:

Date:

Parental Consent forms will be available at the Introductory Session

and are due before student participation.