Annual Cotillion Program

Transcription

1 Annual Cotillion Program Application Packet 1

2 COTILLION OVERVIEW Cotillion Since the organization's founding, Delta Sigma Theta Sorority, Inc. has provided assistance to the challenges of people in the United States. Over the years, many programs addressing education, health, international development, and strengthening of the African American family were established. As a part of the organization's mission, Delta Sigma Theta provides public service initiatives through the Five-Point Program Thrust. In the spring of 2015, Collin County Alumnae Chapter will be hosting its seventh annual Cotillion Ball and would like to invite you to become a part of this legacy. Please take the time to review the enclosed application packet. We encourage you to apply and look forward to working with you. You may send questions to ccac.cotillion@gmail.com. Eligibility and Requirements Applicants must be a Senior for Debutante status or a Junior for Lady in Waiting status. Application must include: A completed and signed application including parental consent forms One completed recommendation letter from a school official/representative One completed recommendation letter from a community leader ~ i.e. minister, employer, or member of Delta Sigma Theta Sorority, Inc. (not a family member) A copy of an official school transcript with a minimum 2.5 GPA based on a 4.0 grading scale A current photograph Mail all information to: Delta Sigma Theta Sorority, Inc. Attn: Cotillion Committee P.O. Box 10 Allen, TX Early Submission: August 3, 2014 Applicants are encouraged to submit by the early submission date, but no applications will be accepted after August 31, 2014 (all mailed applications must be postmarked by 8/31/14). Selection and Notification Selected applicants will be mailed a Letter of Acceptance. The young ladies selected as Debutantes (Senior Class of 2015) and Ladies In Waiting (Junior Class of 2015) will be invited to a Welcome Reception to be held in September Please note any applicants submitting on the final submission date and then extended an invitation to the program will need to submit any initial payment(s) upon acceptance notification. 2

3 COTILLION APPLICATION Please complete each item. Type or print legibly in black ink. Check One: Debutante (12th Grade*) Lady In Waiting (11th Grade*) *During the upcoming academic school year Personal Information Name Address First Middle Last Street City State Zip Home Phone Cell Phone of Birth mm/dd/yy Mother/Guardian Mother/Guardian Address (If different from above) Home Phone Cell Phone Father/Guardian Father/Guardian Address Address Home Phone (If different from above) Cell Phone 3

4 COTILLION PARENTAL CONSENT FORM Applicant s Name First Middle Last PARENT SECTION: This section is to be completed and signed by a parent/guardian. The names listed below will appear on all publications and publicity related to the Debutante or Lady in Waiting Candidate. Father/Guardian Name First Middle Last Mother/Guardian Name First Middle Last If the names listed above will not be presenting your Debutante Candidate at the Cotillion, please list the names and relationship to the Debutante Candidate of those who will. Female Male Relationship Relationship In case of emergency in parent/guardian s absence, please notify: Name Phone Address Parent/Guardian Statement: If selected, I give permission for my daughter to participate in the Cotillion Program. I understand that it will be my financial responsibility to provide the fees necessary to cover the cost of participation for my daughter and to meet all deadlines in order to ensure proper inclusions in Cotillion materials. This includes, but is not limited to, the non-refundable participation fee. Parent/GuardianmName: (Please Print) Signed: : / / 4

5 PARENT CONSENT FORM Dear Parents and Participants: Welcome to the Cotillion Program sponsored by the of Delta Sigma Theta Sorority, Inc. We are here to support and work together to provide a quality program for our community. Please familiarize yourself with the following guidelines and complete all accompanied form. If you have any further questions, please contact one of the Program Chairs 1. Attendance We ask that your child be an active participant in the program. The only way we can have a strong program is with your attendance and support. We expect she will be with us at every session. If that is not possible please contact one of the program chairs at least 24 hours prior to the session. 2. Permission Slips A trip specific Permission Slip must be signed and returned to the Cotillion Program Coordinators before any Student will be allowed to attend an off -site trip/activity otherwise she will not be able to attend that trip. 3. Transportation Parents are responsible for ensuring transportation to and from the program for every session. Unless otherwise notified, members of Collin County are not permitted to provide transportation from the center to any program outing the students will be taking. If you have an extreme circumstance and are unable to transport your child, please contact the program coordinators to see if accommodations can be made. 4. Drop off/pick-up The child must sign in at every session. If a student is picked up late two (2) times, she may not be able to continue participation in the program. 5. Parents Code of Conduct I, or another adult of my choosing, will be ACCESSIBLE by phone in the event of emergency or my child needs to be picked up early for any reason. I will ENCOURAGE the bonding of friendship and development of trust in my child s relationship with her Delta Mentors through regular and consistent attendance of program activities. Therefore, I will not deprive my child of their contact or outings as a means of discipline. I will REMEMBER that as my child s guardian and disciplinarian, it is my responsibility to handle any problems that should arise in her behavior or attitude. I will have my child READY at the time agreed upon for any outings and to call one of the Collin County Alumnae Chapter Cotillion Program Chairs at least 24 hours ahead of time if my child is unable to attend. I will make sure my child is DRESSED APPROPRIATELY for her outings. I will ACKNOWLEDGE that because this relationship is to build sisterhood with the Delta Mentors, I will not ask that others be included in their outings and I will not ask for personal favors from the mentors. I will be AWARE of the activities that my child participates in and share any concerns that I might have with one of the Cotillion Program Committee Chairs. 6. Photo / Media Release I, in consideration of our (my) child s participation in the Cotillion Program, do grant permission for my child s picture to be included in group activity pictures posted on the website of Delta Sigma Theta Sorority, and/or used in publications of Delta Sigma Theta Sorority as related to the Cotillion Program. By my signing this form I indicate that I have read and clearly understand my role in improving my child s future. I ask that my child be permitted to participate in the Collin County Alumnae Chapter Cotillion Program, which will be a continuing program throughout the current school year. I am fully aware that the of Delta Sigma Theta Sorority, Inc sponsors the program and have been advised of the calendar of events scheduled for the program. Signature of Parent/Guardian Home Address: Emergency Phone Number(s): 5

6 Statement of Qualifications I, confirm that I meet all the Cotillion participation criteria listed below and understand that I must maintain these standards throughout the Cotillion Season. Must be a female Junior or Senior between the ages of 16 and 18. Cumulative grade point average of 2.5 or better based on a 4.0 grading scale (verified by official transcript.) Demonstrate interest and involvement in public service and community related activities. Demonstrate goals, aspirations, and plans to pursue an education beyond high school. Evidence of good moral character, which includes but not limited to: No record of poor discipline at school or in the community No criminal, misdemeanor, or court record of any kind Must not be a parent If you are currently pregnant or become pregnant during the Cotillion Season you will become ineligible and not allowed to continue participating in Cotillion activities and Cotillion presentation Must not have previous or current employment in places of entertainment including bars, clubs, etc. Must be able to commit to attending all necessary rehearsals and activities that occur throughout the Cotillion Season. Upon acceptance, the potential participant must be willing to abide by further guidelines. Signed: : / / (Applicant Signature) Signed: : / / (Parent/Guardian Signature) 6

7 Agreement for Prospective Debutante or Lady in Waiting I, (print name), certify that the information provided in this application is complete, true, and accurate. I authorize the of Delta Sigma Theta Sorority, Inc.'s Cotillion Co-Chairs and/or President and Vice Presidents to verify any information provided in this application. I understand that falsification of any information in this application will result in my dismissal from the Cotillion program and that any money received from me or on my behalf will NOT be refunded. I further understand that if I voluntarily withdraw from the Cotillion program any money received from me or on my behalf will NOT be refunded. Applicant s Signature I, (Print name), legal parent or guardian of (Print applicant s name), certify that the information provided in this application is complete, true, and accurate. I authorize the Collin County Alumnae Chapter of Delta Sigma Theta Sorority, Inc.'s Cotillion co-chairs and/or President and Vice Presidents to verify any information provided in this application. I understand that falsification of any information in this application will result in her dismissal from the Cotillion program and that any money received from her or on her behalf will NOT be refunded. I further understand that if she voluntarily withdraws from the Cotillion program or is removed from the Cotillion program for failure to adhere to guidelines and policies, any money received from her or on her behalf will NOT be refunded. Parent/Guardian Signature 7

8 RELEASE FROM LIABILITY Under the direction of Delta Sigma Theta Sorority s national Program Planning and Development Committee, Collin County Alumnae (CCAC) has implemented a chapter Risk Management Policy to ensure that all of our youth programs (including, but not limited to the Cotillion, Delta Academy, Delta GEMS and EMBODI) are administered consistently and in a manner that is in the interest of both the participating youth and Delta. (i.e., minimize any harm or injury to the youth as well as the probability of Delta incurring liability). All persons working with any of CCAC youth initiatives must adhere to this policy and complete the Youth Initiatives application and screening process. In consideration of being permitted to participate in the Delta Sigma Theta Sorority, Inc. Collin County Alumnae Chapter Cotillion Program, the undersigned, on behalf of myself, my heirs, executors, administrators, and assigns (collectively the Releasor ) hereby: 1. Remise, release, and forever discharge Delta Sigma Theta Sorority, Inc., Delta Sigma Theta Sorority, Inc., its officers, members, directors, shareholders, affiliates, agents, representatives, successors, assigns, and executors (collectively the Releasees ), of and from all actions, causes of action, claims, demands and damages, costs, expenses (collectively the Claims ) in respect of injury, loss, damage, or death to Releasors or associated property howsoever caused, arising by reason of or during participation and/or involvement in the Delta Sigma Theta Sorority, Inc. Cotillion Program, and notwithstanding that any Claim may have been contributed to or occasioned by the negligence of any of the Releasees. 2. Indemnify and save harmless the Releasees from and against any and all liability incurred to any or all of them arising as a result of or in any way directly or indirectly connected to, or arising out of, participation in the Delta Sigma Theta Sorority, Inc. Cotillion Program. 3. Understand and acknowledge that Delta Sigma Theta Sorority, Inc. does not carry or maintain health, medical or disability insurance coverage for Releasor and therefore agrees to assume responsibility for such insurance coverage on the undersigned, heirs, executors, or administrators. 4. Agrees that in the event than any provision of this Release and Indemnity is held to be invalid or unenforceable by any court of competent jurisdiction, the invalidity or unenforceability of such provision will not affect the remaining provisions of this Release and Indemnity which shall continue to be enforceable. 5. Remise, release, and forever discharge the Releasees whatsoever, whether or not well founded in fact or in law, and from all suits, debts, dues, sums of money, accounts, reckonings, notes (or bonds), bills, specialties, covenants, contracts, controversies, agreements, promises, trespasses, damages, judgments, executions, claims and demands whatsoever, at law or in equity that Releasor ever had, now has, or that the Releasor hereafter may have against the Releasees hereby released by reason of any matter, cause or thing whatsoever up to and including the day of the date of this release in accordance with participation in Delta Sigma Theta Sorority, Inc. Cotillion Program. 6. Acknowledge and agree it is the specific intent and purpose of this instrument to release and discharge any and all claims and causes of action of any kind or nature whatsoever, whether known or unknown and whether specifically mentioned or not, which may exist or might be claimed to exist at or prior to the date of this release and undersigned specifically waives any claim or right to assert that any cause of action or alleged cause of action or claim or demand has been, through oversight or error or intentionally or unintentionally, omitted from this release. 7. Agree not to make claim or take proceedings against the Releasees or any other person or entity which may claim contribution or indemnity under the provisions of any statue or otherwise. 8. It is also understood that no legal action will be brought against of Delta Sigma Theta Sorority, Inc. or subsidiaries or authorized personnel by you or your child because of any matter directly or indirectly related to you and your child s participation in any session or events held by the Collin County Alumnae Chapter of Delta Sigma Theta Sorority, Inc. 8

9 RELEASE FROM LIABILITY (continued) In witness whereof, the Releasor has executed this release on this day of, 2. The undersigned hereby acknowledges reading, understanding, and agreeing with the foregoing. Printed Name of Releasor Signature of Releasor Printed Name of Witness Signature of Witness 9

10 STUDENT MEDICAL INFORMATION / RELEASE This form is to be completed and signed by parent/guardian of student. To the parent/guardian: The health of the student is the responsibility of her parents or guardians. Collin County Alumnae Chapter strongly recommends annual health examinations, dental checkups, and immunizations against preventable diseases. It is the right of the organization to be assured, as far as possible, that the participants are physically able to take part in the Collin County Alumnae Chapter Cotillion Program activities. Student s Name: Family Physician s Name: Student s of Birth: Parent/Guardian s Full Name: Emergency Contact Number: Physician s Phone Number: Insurance Info: Please list any allergies, illnesses, medications, special needs or injuries that the Collin County Alumnae Chapter Cotillion Program committee should be aware of to make the Participant s experience a positive one. I agree that in the event Participant is involved in an incident that requires medical attention, the Parent will be responsible for making all decisions related to all medical and survival procedures for Participant while Participant is participating in the Collin County Alumnae Chapter Cotillion Cotillion Program, Program including but not limited to decisions about medical care, the administration of drugs, and the performance of any and all life sustaining procedures. Parent further agrees to make any and all arrangements for Participant s transportation and admittance to any hospital, clinic, or health care facility in the event of any emergency situation involving Participant. In the event that the parent(s) or emergency contacts cannot be reached during a medical emergency, the Parent gives Delta Sigma Theta Sorority, Inc. permission to make decisions regarding any and all medical and survival procedures for Participant. The Parent agrees that Delta Sigma Theta Sorority Inc. will not be held liable for any accident or losses, however caused. Student s Name Signature of Parent/Guardian: Address Phone 10

11 ACTIVITY CODE OF CONDUCT I understand that my attitude and behavior are central to the success of this activity sponsored by the Collin County Alumnae Chapter. Therefore, for the good of this activity, as well as for myself and my fellow group members, I agree to abide by the following: 1. I will cooperate with all adults in charge. I will be sensitive to the needs of each participant. 2. I will respect the people and places with which I come in contact. 3. I will participate in all required activities & discussions, be on time for all schedules activities, be open to new ideas, inform adults of my whereabouts at all times, and return to/remain in my assigned area. I will always take a buddy with me wherever I go. In the event I must miss an event, I will contact one of the program chairs at least 24 hours ahead of the activity. 4. I understand that obscene language and the use of alcohol, tobacco, and illegal or unauthorized drugs, and fighting will not be tolerated. Such usage during the activity may result in immediate dismissal from the program. 5. I will remember that I am a member of a program sponsored by the women of the Collin County Alumnae Chapter of Delta Sigma Theta Sorority, Inc. and I must abide by a high standard of conduct. My behavior will reflect the high values and expectations for conduct described in this code of conduct and lady like etiquette. 6. I will be responsible for all my personal belongings and equipment and will label all personal items. I agree to hold harmless all members the of of Delta Sigma Theta Sorority, Inc. or any other individual or program provider responsible for my loss or damage due to my negligence or willful conduct. 7. I will treat property provided by the of Delta Sigma Theta Sorority, Inc. and/or an outside provider with care. I understand that I will be assessed for damages, financial and in equity, to any such property caused by my use, if negligent or abusive. 8. I will observe all safety regulations established for programs, recreational and personal activities. I affirm that my registration information is correct, including all known allergies, dietary considerations, and routine medicines. I will report immediately all injuries or illnesses to the adult in charge of the activity. 9. I understand that I will receive two warnings for unacceptable behavior. After two warnings, my parent/guardian may be notified. I understand if I am sent home early due to any misconduct, it will be my parent's responsibility to provide transportation regardless of the time of day or night. I also understand that any additional costs for transportation will be my parent's responsibility. 10. I understand that absences may prohibit me from being able to participate on field trips. It is at the Cotillion Program Committee s discretion and they have final authority in the decision. Student Signature I understand and agree with the above responsibilities fully accepted by my child/ward. Should it be necessary, I will provide transportation for my child/ward regardless of the time of day or night. I will not hold the or its members responsible if my daughter/ward is sent home early due to misconduct. I have provided accurate health and medical information about my daughter/ward. Parent Signature 11

12 PROGRAM LIABILITY FORM Under the direction of Delta Sigma Theta Sorority s national Program Planning and Development Committee, Collin County Alumnae has implemented a chapter Risk Management Policy to ensure that all of our youth programs (including, but not limited to the Cotillion, Delta Academy, Delta GEMS and EMBODI) are administered consistently and in a manner that is in the interest of both the participating youth and Delta. (i.e., minimize any harm or injury to the youth as well as the probability of Delta incurring liability). All persons working with any of CCAC youth initiatives must adhere to this policy and complete the Youth Initiatives application and screening process. This signed agreement officially absolves the of Delta Sigma Theta Sorority, Inc. and the Grand Chapter of Delta Sigma Theta Sorority, Inc. of any and all liability from any accidents or injuries resulting from you or your child s participation in any event in itself and travel to and from any event. Furthermore, it is understood that any and all medical expenses incurred due to injuries sustained at any project or event organized by the Collin County Alumnae Chapter of Delta Sigma Theta Sorority, Inc. is the sole responsibility of the participant in the event(s). This is inclusive of pre-existing conditions, which may become aggravated due to you or your child s participation in any event(s). It is also understood that no legal action will be brought against of Delta Sigma Theta Sorority, Inc. or subsidiaries or authorized personnel by you or your child because of any matter directly or indirectly related to you and your child s participation in any session or events held by the of Delta Sigma Theta Sorority, Inc. Parent/Guardian s Authorization (PLEASE PRINT) As a parent/guardian of, I request she attend the Collin County Alumnae Chapter Cotillion Program and take part in all activities. In case of emergency the program coordinator has my permission to give minor first aid or take my child to an emergency treatment facility. I, (parent/guardian), further request the program coordinator or other program volunteer call a physician for medical care for my child, (child s name), should an emergency arise. I understand that the program staff will make a conscientious effort to locate me via the telephone number provided at drop off as well as attempting to contact me at, before any action is taken but if it is not possible to locate me, I understand that I will accept all medical expenses. By signing your name, you are stating that you have read, fully understand and are in agreement with this waiver. Signature or Parent/Guardian 12

13 REVISED APPENDIX 15 FIELD TRIP PERMISSION I/We, ( Parent/Guardian ), as parent(s) or legal guardian(s) of ( Youth or child ), give permission for my/our child to participate in Youth Initiatives Program s (the Initiatives ) activities taking place off site. I/we understand that transportation to and from these activities will be provided for my/our Youth by the Chapter. I/We understand that the field trips are part of the Initiatives, and if I/we choose not to have my/our child participate in one or more off-site activities, I/we must make other care arrangements for my/our child during the times of that field trip activity, if it is on the day of a regularly-scheduled meeting. I/We have read Delta Sigma Theta Youth Initiative Guidelines for Supervising Off-Site Activities ( Youth Initiative Guidelines). I/We believe that our child is mature enough to follow the Youth Initiative Guidelines and that he/she will act responsibly during all off-site activities. I/We assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, except those arising from gross negligence or intentional infliction of harm by the Initiatives, its officers, agents or employees. I/We do hereby agree to release and hold harmless the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board members, employees, members, representatives, agents, and assigns from any and all claims, costs, suits, actions, judgments, and expenses for any damage, loss, or injury to my/our child or damage to my/our child s property arising from my/our child s participation in field trips, other than damage, loss, or injury that results from gross negligence or intentional infliction of harm by the Initiatives, Delta Sigma Theta Sorority, Incorporated, its officers, National Executive Board members, employees, members, representatives, agents, and assigns. ****************** Parent/Guardian Signature Print Name Parent/Guardian Signature Print Name 13

14 *************** Youth Acknowledgment and Signature: I,, have read the Delta Sigma Theta Youth Initiative Guidelines for Supervising Off-Site Activities ( Youth Initiative Guidelines). I understand the Youth Initiative Guidelines. I am responsible enough to follow the Youth Initiative Guidelines and promise to do so during all off-site activities. Youth Signature Print Name Name of Youth Program Delta Sigma Theta Sorority, Inc. Revised Appendix 15 Risk Management Manual 14