Foothill Alumnae Chapter

Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc.

2016-2017

E.M.B.O.D.I. Empowering Males to Build Opportunities for Developing Independence Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc. 2016-2017 E.M.B.O.D.I. Program Application 2 | P a g e STUDENT INFORMATION ______

NAME: ______DATE:______First Middle Last

ADDRESS: ______Street Address Apt.

CITY: ______ZIP CODE: ______

HOME PHONE: ( )______CELL PHONE: ( ) ______

EMAIL ADDRESS: ______

DATE OF BIRTH: _____/______/___ AGE: ______T-SHIRT SIZE: ______(mm) (dd) (yyyy)

PARENT’S/GUARDIAN’S NAME:

______First M.I. Last

HOME PHONE: ( )______CELL PHONE: ( ) ______

EMERGENCY CONTACT: ______First M.I. Last

Empowering Males to Build Opportunities for Developing Independence rev.8/22/15 Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc. 2016-2017 E.M.B.O.D.I. Program Application 3 | P a g e CONTACT NUMBER: ( )______ALT NUMBER: ( ) ______

MEDICAL (To Be Completed By Parent/Guardian)

IS APPLICANT: (1) UNDER A DOCTOR’S CARE AT THIS TIME? YES______NO ______

IF YES, DOCTOR’S NAME ______

DOCTOR’S PHONE NUMBER ______

(2) TAKING ANY MEDICATIONS? YES ______NO ______

IF YES, WHAT ARE YOU TAKING? ______

DOES APPLICANT HAVE ALLERGIES (food, dust, pollen, animals, drugs, etc.)? YES ______NO ______

IF YES, LIST THEM ______

IS THERE ANY ACTIVITY THAT THE APPLICANT CANNOT PARTICIPATE IN? YES______NO______

IF YES, PLEASE LIST: ______

EDUCATION: (To Be Completed By Applicant)

HAVE YOU PARTICIPATED IN E.M.B.O.D.I. BEFORE? YES ______NO ______

IF YES, EXCLUDING THIS YEAR HOW MANY YEARS HAVE YOU ATTENDED? ____

Empowering Males to Build Opportunities for Developing Independence rev.8/22/15 Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc. 2016-2017 E.M.B.O.D.I. Program Application 4 | P a g e

SCHOOL: ______

GRADE: ______COUNSELOR: ______

MATH LEVEL/CLASS (i.e. Algebra I): ______

2015 - 2016 Final Grades: MATH: ______ENGLISH: ______SCIENCE: ______HISTORY: ______READING: ______

HAVE YOU PASSED THE CAHSEE (10TH grade and above only)? YES _____ NO _____

HAVE YOU TAKEN THE SAT OR ACT (9th-12th grade only)? Yes______NO______

LIST YOUR FAVORITE SCHOOL SUBJECTS: ______

______

LIST THE SCHOOL CLUBS AND TEAMS YOU BELONG TO: ______

LIST THE CLUBS AND ACTIVITIES YOU PARTICIPATE IN OUTSIDE OF SCHOOL:

______

LIST YOUR HOBBIES: ______

Empowering Males to Build Opportunities for Developing Independence rev.8/22/15 Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc. 2016-2017 E.M.B.O.D.I. Program Application 5 | P a g e

______(Student Name) has my permission to attend the E.M.B.O.D.I. program. In case of an emergency, I give my permission to apply whatever lifesaving first aid is necessary until I can be reached.

______PARENT/GUARDIAN’S SIGNATURE DATE

______APPLICANT’S SIGNATURE DATE

APPLICATION DUE OCTOBER 3, 2015 PROGRAM ORIENTATION: SATURDAY, OCTOBER 17, 2015

**** A COPY OF APPLICANT’S 2015-2016 SCHOOL YEAR REPORT CARD MUST BE SUBMITTED AT THE FIRST MEETING.*** IF YOU HAVE ANY QUESTIONS, REGARDING THIS APPLICATION, PLEASE CONTACT: DIERDRE GAY @ (213) 718-4421 EMAIL: [email protected]

Empowering Males to Build Opportunities for Developing Independence rev.8/22/15