<p> Foothill Alumnae Chapter Delta Sigma Theta Sorority, Inc.</p><p>2016-2017</p><p>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 ______</p><p>NAME: ______DATE:______First Middle Last</p><p>ADDRESS: ______Street Address Apt.</p><p>CITY: ______ZIP CODE: ______</p><p>HOME PHONE: ( )______CELL PHONE: ( ) ______</p><p>EMAIL ADDRESS: ______</p><p>DATE OF BIRTH: _____/______/___ AGE: ______T-SHIRT SIZE: ______(mm) (dd) (yyyy)</p><p>PARENT’S/GUARDIAN’S NAME:</p><p>______First M.I. Last</p><p>HOME PHONE: ( )______CELL PHONE: ( ) ______</p><p>EMAIL ADDRESS: ______</p><p>EMERGENCY CONTACT: ______First M.I. Last </p><p>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: ( ) ______</p><p>EMAIL ADDRESS: ______</p><p>MEDICAL (To Be Completed By Parent/Guardian)</p><p>IS APPLICANT: (1) UNDER A DOCTOR’S CARE AT THIS TIME? YES______NO ______</p><p>IF YES, DOCTOR’S NAME ______</p><p>DOCTOR’S PHONE NUMBER ______</p><p>(2) TAKING ANY MEDICATIONS? YES ______NO ______</p><p>IF YES, WHAT ARE YOU TAKING? ______</p><p>DOES APPLICANT HAVE ALLERGIES (food, dust, pollen, animals, drugs, etc.)? YES ______NO ______</p><p>IF YES, LIST THEM ______</p><p>IS THERE ANY ACTIVITY THAT THE APPLICANT CANNOT PARTICIPATE IN? YES______NO______</p><p>IF YES, PLEASE LIST: ______</p><p>EDUCATION: (To Be Completed By Applicant) </p><p>HAVE YOU PARTICIPATED IN E.M.B.O.D.I. BEFORE? YES ______NO ______</p><p>IF YES, EXCLUDING THIS YEAR HOW MANY YEARS HAVE YOU ATTENDED? ____</p><p>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</p><p>SCHOOL: ______</p><p>GRADE: ______COUNSELOR: ______</p><p>MATH LEVEL/CLASS (i.e. Algebra I): ______</p><p>2015 - 2016 Final Grades: MATH: ______ENGLISH: ______SCIENCE: ______HISTORY: ______READING: ______</p><p>HAVE YOU PASSED THE CAHSEE (10TH grade and above only)? YES _____ NO _____</p><p>HAVE YOU TAKEN THE SAT OR ACT (9th-12th grade only)? Yes______NO______</p><p>LIST YOUR FAVORITE SCHOOL SUBJECTS: ______</p><p>______</p><p>LIST THE SCHOOL CLUBS AND TEAMS YOU BELONG TO: ______</p><p>LIST THE CLUBS AND ACTIVITIES YOU PARTICIPATE IN OUTSIDE OF SCHOOL: </p><p>______</p><p>LIST YOUR HOBBIES: ______</p><p>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</p><p>______(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. </p><p>______PARENT/GUARDIAN’S SIGNATURE DATE</p><p>______APPLICANT’S SIGNATURE DATE</p><p>APPLICATION DUE OCTOBER 3, 2015 PROGRAM ORIENTATION: SATURDAY, OCTOBER 17, 2015</p><p>**** 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]</p><p>Empowering Males to Build Opportunities for Developing Independence rev.8/22/15</p>