PARENT WORKBOOK APPLICATION - and - Saginaw Alumnae Chapter
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Saginaw Alumnae Chapter
Delta Sigma Theta Sorority, Inc.
PARENT WORKBOOK
and
APPLICATION
TABLE OF CONTENTS
CONTENTS PAGE
Welcome 2
About Miss Delta Doll Pageant 3
Financial Requirements and Fundraisers 4
Parent Requirement 5
Doll Contestant Requirements 5
Ernestine Mack Clark Miss Delta Doll Rules 5
Ernestine Mack Clark Miss Delta Doll Code of Ethics 6
How to be Crowned Miss Delta Doll 7
APPLICATION PAGE
Contact/Personal Information (Please Print) 8
Profile 8-9
Emergency Contact Information 9-10
Health Information and Treatment Information Packet 10
Health Information 10-11
Health History 11-12
Medication Authorization Form 13
Parental Permission Form/Administration of PRESCRBED 14
MEDICATION
Medication Administered Procedure 15
Nonprescribed Medication Permit 16
Physician/Insurance Information 16
Youth Pick-Up Authorization Form 17
Parent Waiver and Permission to Transport Youth 18
Off-Site Permission 19
Youth Sign-In/Sign-Out Policy 20
Parental/Guardian Affirmation 21
Waiver and Release 21
Rehearsal, Self-Development Activities & Picture Times and Dates 22
FUNDRAISER LETTERS and DOCUMENTATION PAGE
Patrons & Ad Letter and Patron and Ad Form 24-25
Krispy Kreme Fundraiser Form 26
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020
WELCOME
Parents,
Welcome to the 2020 Ernestine Mack Clark Miss Delta Doll Parent Meeting. The ladies of Delta Sigma Theta
Sorority, Inc., Saginaw Alumnae Chapter are excited to work with you and your daughter. Our national sorority
has a Five Point Thrust: Economic Development, Political Awareness, Physical and Mental Health,
International Awareness Education Development. The Ernestine Mack Clark Miss Delta Doll falls under two
thrusts, Education Development and Economic Development while also addressing the sorority’s love of the
arts. Our goal is to provide the dolls an artistic cultural experience that they will never forget.
Dolls will participate in the following:
1. Understand their individual brilliance
2. Instill the need to excel academically
3. Create caring and community minded young girls
4. Actively involve them in service learning and community service opportunities
5. Provide tools to sharpen and enhance their skills to achieve academic success
6. Assist in goal setting and planning for their future
Covering the following areas
Etiquette – Dressing for the Occasion; Etiquette – Public Graces;
The Miss Delta Doll Pageant will be held at Horizons Conference Center or The Dow Event Center
Sincerely,
LaNasia C. Hood, Chair
Ernestine Mack Clark Miss Delta Doll Committee
Delta Sigma Theta Sorority, Inc., Saginaw Alumnae Chapter
Karen Lawrence-Webster, Chapter President
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020
ABOUT MISS DELTA DOLL PAGEANT
Date: Saturday, April 18, 2019
Time: 5:00 p.m.
Location: Horizon Conference Center or The Dow Event Center
Ticket: $40
Committee Members: LaNasia Hood, Fontella Smith, Dana McKenzie-Simmons, RoShawnda Brown, Shalanda
Ellison, Sheronda Hodgers, Dawn Tatum, and Karen Lawrence-Webster
Theme – Dolls in Candyland - “Sugar and Spice and Everything Nice”
Purpose
Delta Sigma Theta Sorority, Inc., Saginaw Alumnae Chapter introduced the Ernestine Mack Clark Miss Delta
Doll Pageant to the Saginaw community in 1982. The primary purpose of this event is to generate revenue for
the chapter’s scholarship program for high school seniors. The pageant provides a platform for girls, ages 6 –
11, to implement the Five Point Thrust of Delta Sigma Theta Sorority, Incorporated and have an artistic
cultural experience.
Point 1 – Economic Development
Through fundraising requirements, the girls will creatively support black owned businesses in a spirit of
competition.
Point 2 – Political and Social Action
The girls will be required to participate in a community activity that will provide awareness to community
needs.
Arts and Letters – present talents and gifts to the greater Saginaw community.
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020FUNDRAISER and FINANCIAL REQUIREMENTS
1. KRISPY KREME DOUGHNUTS
• Start Date: January 9, 2020 End Date: January 30, 2020 Pick Up Date: February 6, 2020
• Minimum sale of 40 boxes sold at $10/box ($400)
• Note: If sale requirements are met, $250 of the sales will be given back to Parent to cover attire
for Pageant Contestant and her Escort (Ages 6-11)
• Doll Attire: White Pageant Dress, White shoes, White Gloves and Pearl Necklace
• Escort: Black Tuxedo
2. SOUVENIR BOOKLET: Patrons and advertisements – minimum amount - $300
• Start Date: February 6, 2020 End Date: March 5, 2020 Submit Money Date: March 5, 2020
• Patrons: $5 per name
• Advertisements:
• Full Page $75.00
• Half Page $50.00
• Quarter Page $25.00
• Eighth Page (Business Card) $10.00
Patron example – Mr. and Mrs. Joe and Marth Smith = $5.00 (one name)
Mr. and Mrs. Joe and Marth Smith and Family = $10.00 (two names)
3. TICKET SALES: $40/Ticket
• Start Date: March 5, 2020 End Date: April 9, 2020 Submit Money Date: April 9, 2020
NOTE: Fundraisers numbered 1-3 count towards the crowning of Miss Delta Doll.
All funds raised for the “Miss Delta Doll Pageant” MUST be turned in by money orders or checks.
4. DELTA DOLL STORE: Prices of Items Varies
• Selling Miss Delta Doll Apparel and nick knacks
• Water Bottle
• T-Shirt (Picture of Pageant Contestant on Back)
• Lanyard
• Hand Sanitizer
• Miss Delta Doll Journal
• Miss Delta Doll Pin
• Miss Delta Doll Large and Small Gift Bags
• Miss Delta Doll Sling Bag
• Miss Delta Doll Socks
• And Much More!
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020PAGEANT CONTESTANT REQUIREMENTS
Each Pageant Contestant is required to:
During the Pageant:
• Perform a two (2) minute group routine or (1:30) 1 minute and 30 second Talent at the Pageant
(At the discretion of committee Members)
• Answer one interview question
• Stay for the entire event; start to finish
Leading up to the Pageant:
• Participate in a group presentation
• Participate in Self Development Activities
• Participate in a Community Service Project
• Participate in a Community Event
PAGEANT CONTESTANT REQUIREMENTS
PARENT REQUIREMENTS
All Parents are required to:
• Be on time to meetings and events.
• Attend all schedule meetings every month.
• Participate in Community Event (Optional)
• Assist in doing the Service Project (Optional)
• Show our Pageant Attire Committee contestants’ and escorts’ attire. Must save receipt and submit to
the Attire Committee.
• Assist their child with all fundraisers and adhere to each deadline.
• Contact Parent Liaison if contestant is sick and cannot make schedules events, activities, and/or
rehearsals.
• Transport contestants and escorts to all rehearsals, events and or activities.
PAGEANT RULES
1. Each parent/guardian must assist their child with fundraiser events for the pageant.
2. All deadlines MUST be adhered to with NO EXCEPTIONS. Extensions will only be made at the
discretion of the Sorority.
3. All money raised for the “Miss Delta Doll Pageant” MUST be turned in by money orders or checks.
Checks from businesses are to be payable to Delta Sigma Theta Sorority.
4. The Doll who raises the most money will be crowned “Miss Delta Doll”
5. All contestants MUST prepare a talent and or participate in the group routine.
6. Sorority members WILL NOT BE JUDGES for the talent competition. ALL judges will be chosen from the
community.
7. Each participant is expected to attend all rehearsals.
8. All parents will select an escort for their Doll. Delta Doll parents or parents of the escorts are
responsible for the cost of their tuxedos.
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020MISS DELTA DOLL CODE OF ETHICS
All members and any Delta volunteers working with participants in the Miss Ernestine Mack Clark Pageant are
expected to observe a code of ethics. This Code of Ethics embodies the affirmation of our commitment
to follow tenets that are integral to Delta’s youth initiatives.
1. We will treat youth with respect, care and acceptance. We know that all young people are valuable and
capable of helping others and improving their communities. We will use a democratic approach when working
with youth.
2. We will honor our volunteer commitment. We will strive to live up to our volunteer commitment by
working the hours necessary to fulfill the volunteer role we have accepted.
3. We will seek training for our volunteer role. We will participate in meetings, self-study or other training
opportunities, which will help us work more effectively with youth and adults.
4. We will provide a safe environment. We will not harm youth or adults in any way, whether through sexual
harassment, physical force, verbal or mental abuse, neglect or other harmful activities.
5. We will abstain from using alcohol or any illegal substance while working with, or while responsible for
youth; neither will we allow youth to use any such substance while under our supervision. For states where
substances, such as marijuana are legal, we will abstain from use while working with or while responsible for
youth.
6. We will obey the laws of the locality, state and nation.
7. We will strive to be a positive role model. By our example, we will help youth learn to respect and
cooperate with others. We will teach others to compete honestly and fairly.
8. We will work as a “team player” for the good of all persons. We will work cooperatively with other adult
volunteers for the good of all involved in the youth initiatives.
9. We will work within the Delta Sigma Theta Sorority system. As a volunteer, we are accountable for our
actions. If our personal conduct is deemed to be in violation of any of Delta’s policies, we understand we may
be relieved of our volunteer role.
10. We will not have unsanctioned outside contact with any youth participant; without the expressed written
permission from the parent/guardian or the parent/guardian is physically present during the outside contact.
Sincerely,
The Miss Ernestine Mack Clark Miss Delta Doll Committee
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020HOW TO BE CROWNED MISS DELTA DOLL
Miss Delta Doll is selected based upon the amount of money raised from all fundraisers. The Pageant
Contestant with the highest amount of funds collect from all fundraisers is THE WINNER.
M
Miss Delta Doll Winner Requirements
• Represent the chapter at the following events
1. Delta Gem Events: TBA
2. PowerPlay: November 2020 at the Saginaw Children’s Museum, Time: TBA
▪ Host a jump rope competition or slime workshop or lip-gloss workshop
Miss Delta Doll will receive the following:
➢ 5% of total amount raised returned back
➢ A certificate of participation
➢ A Delta Doll sash
➢ A trophy
➢ A Delta Doll t-shirt
➢ A grab bag of goodies
➢ Picture will be featured in Word Up Magazine and Michigan Banner
➢ A crown
All Delta Dolls will receive the following:
➢ A certificate of participation
➢ A Delta Doll sash
➢ A Delta Doll t-shirt
➢ A grab bag of goodies
➢ A crown
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020CONTACT/PERSONAL INFORMATION (PLEASE PRINT)
Name_____________________________________________________________________________________
Address___________________________________________________________________________________
Daytime Phone______________________________________email___________________________________
Emergency Contact # _____________________________ Birthday ______________________Age __________
Parents: __________________________________________________________________________________
Siblings: __________________________________________________________________________________
PROFILE
Name of School ________________________________________Church ______________________________
Grade __________________ Teacher ___________________________________________________________
Favorite Subject(s) __________________________________________________________________________
Hobbies/Activities ___________________________________________________________________________
Pageant Talent _____________________________________________________________________________
What do you want to be when you grow up? _____________________________________________________
Favorite Color ___________________________Favorite Food________________________________________
If Pageant Contestant was given the opportunity to make any dream come true, what would it be and why?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Dress Size ____________________________________ T-shirt Size ___________________________________
Days of the week available for rehearsals: _______________________________________________________
Name of Escort _____________________________________________________________________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Do you need help with an escort? Yes or No
Special dietary or health issues the Sorority should be aware of during the course of the pageant
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Parents: What are your hopes and dreams for your daughter? What words of encouragement do you have
for her?
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Parent/Guardian #1
Name_____________________________________________________ Relationship____________________
Street Address______________________________________________________________________________
City ________________________________________ State__________________ Zip Code _______________
Home Phone_______________________ Work Phone____________________ Cell______________________
E-mail address: _____________________________________________________________________________
Parent/Guardian #2
Name_____________________________________________________ Relationship____________________
Street Address______________________________________________________________________________
City ________________________________________ State__________________ Zip Code _______________
Home Phone_______________________ Work Phone____________________ Cell______________________
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.
Emergency Contact #1
Name_____________________________________________________ Relationship____________________
Home Phone_______________________ Work Phone____________________ Cell______________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Emergency Contact #2
Name_____________________________________________________ Relationship____________________
Home Phone_______________________ Work Phone____________________ Cell______________________
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
MEDICAL INFORMATION AND TREATMENT AUTHORIZATION PACKET
Today's Date: ___________________________________
Youth Name ______________________________ Date of Birth: __________________________________
Address: _____________________________________________________City__________________________
State: ________________________________ Zip Code: _______________
Parent/Guardian Name: _____________________________ 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. Also
complete and submit the Medication Authorization Form if your child has health conditions that
require medication during the Program day.
Asthma Inhaler required at Program: Yes or No
Vision Problems: Yes or No Hearing Problems: Yes or No
Glasses: Yes or No Hearing Aid(s): Yes or No
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Contacts: Yes or No ADD/ADHD: Yes or No
Other:_____________________________________________________________________________________
__________________________________________________________________________________________
Allergies/Sensitivities (be specific):
Foods: ____________________________________________________________________________________
Medicines: ________________________________________________________________________________
Bee sting or insect bite: ________________________________________ Other: _______________________
List all medications and dosages your child receives on a continual basis:
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? Yes No
Parent/Guardian Name: ____________________________
Does Parent/Guardian live at home with child? Yes No
Is/Has child been under the regular supervision of a physician? Yes No
Name, address, and phone number of physician: __________________________________________________
__________________________________________________________________________________________
Date of last physical exam: __________________________
Health and Developmental History: Childhood illness: Check any that apply
Measles Mumps Chickenpox
Rheumatic Fever Hay Fever Epilepsy
Whooping Cough Poliomyelitis Diabetes
Three Day Measles (Rubella) Asthma Ten Day Measles (Rubella)
Other (please list):____________________________________________________________________________
___________________________________________________________________________________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Does child have any significant health history, conditions, communicable illness, or restrictions that may affect
child’s participation in the Ernestine Mack Clark Miss Delta Doll 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 Ernestine Mack Clark Miss Delta Doll 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: _____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Frequency Taken: ___________________________________________________________________________
__________________________________ (For any medications or treatment required during the course of the
Ernestine Mack Clark Miss Delta Doll youth initiatives program, a Medication Authorization Form should be
completed and submitted with this form.)
Does child take any over the counter medications frequently? Yes No
Name of the medications: _______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Frequency Taken: _______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020MEDICATION AUTHORIZATION FORM
(To be filled out by the physician dispensing the medication)
Name of Minor _____________________________________________________________________________
Medication #1 ______________________________________________________________________________
Time of administration _______________________________________________________________________
Reason for medication _______________________________________________________________________
Route of administration ______________________________________________________________________
Possible side effects and significant information ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Medication #2______________________________________________________________________________
Time of administration _______________________________________________________________________
Reason for medication _______________________________________________________________________
Route of administration ______________________________________________________________________
Possible side effects and significant information ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Medication #3 ______________________________________________________________________________
Time of administration _______________________________________________________________________
Reason for medication _______________________________________________________________________
Route of administration ______________________________________________________________________
Possible side effects and significant information ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician’s signature/Date: __________________________________________________________
Physician’s telephone number: _______________________________________________________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020PARENTAL PERMISSION FORM ADMINISTRATION OF PRESCRIPTION MEDICATION
I/We hereby give permission for___________________________________________________(CHILD) to take
medication at the Ernestine Mack Clark Miss Delta Doll youth initiatives program as ordered by his/her
physician.
I/We understand that it is my/our Child’s responsibility to report to at the appropriate time for the
administration of the medication.
I/We further understand that it is my/our responsibility to furnish this medication and any authorized refills.
I/We further understand that Delta Sigma Theta Sorority, Incorporated (“DST”), its officers, National Executive
Board, employees, members, local Chapters, representatives, agents, affiliates, assigns, the Ernestine Mack
Clark Miss Delta Doll youth initiatives program, its agents, and/or any employee who administers any drug to
my/our child, in accordance with written instructions from the prescriber, shall not be liable for damages as a
result of an adverse drug reaction or any other injury suffered by my/our child due to the administration or
failure to provide the drug.
The Ernestine Mack Clark Miss Delta Doll youth initiatives program reserves the right to refrain from
administering medication if in the judgment of the Ernestine Mack Clark Miss Delta Doll youth initiatives
program, or other authorized Program officer, agent, or employee the circumstances do not warrant
medication administration.
I/We understand that the medication must be brought to the Ernestine Mack Clark Miss Delta Doll youth
initiatives program by me/us in the original appropriately labeled container.
If I/we cannot bring the medication to the Ernestine Mack Clark Miss Delta Doll youth initiatives program,
I/we will call the Ernestine Mack Clark Miss Delta Doll youth initiatives program to inform them that my/our
child will be bringing it, indicating the amount of medication in the container.
____________________________________________________ _____________________________
Parent/Guardian Signature Date
____________________________________________________ _____________________________
Parent/Guardian Signature Date
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020MEDICATION ADMINISTRATION PROCEDURES
Prescription Medication
1. We require the Medication Authorization Form to be completed by the prescribing physician and the
parent. For each prescription medication ordered, the physician must give the following information: (1) the
student’s name, (2) the medication, (3) the dosage, (4) the time of administration, (5) the reason for
administration, (6) the route of administration, (7) the possible side effects, and (8) any other significant
information. The form must then be signed and dated by the prescribing physician. Signed parental consent is
also required for each medication. This consent releases Delta Sigma Theta Sorority, Incorporated, the
Ernestine Mack Clark Miss Delta Doll youth initiatives program, and their officers, National Executive Board,
employees, members, local Chapters, representatives, agents, affiliates, and assigns from liability if the
medication causes adverse reactions. The Medication Authorization Form is updated annually.
2. The original prescription container must accompany all medication to be given at the Ernestine Mack Clark
Miss Delta Doll youth initiatives program. Medications should be brought to the youth initiatives program by
the parent or responsible adult and taken to The Parent Liaison. The original prescription container should be
labeled with the following information: name of student, name of medication, dosage of medication to be
given, frequency of administration, route of administration, name of physician ordering medication, date of
prescription, and expiration date.
3. If possible, the parent should provide days’ worth of the medication if it is to be given every day. It is the
parent’s responsibility to provide adequate refills on a timely basis.
4. All medication is kept in a locked cabinet or locked container at all times. If not retrieved by a parent or
responsible adult, all medication will be destroyed one week after the expiration date or at the end of the
term for the Ernestine Mack Clark Miss Delta Doll youth initiatives program.
5. A record will be maintained every time a medication is given. The record includes the student’s
name, date, time of administration, and dosage.
Over-the-Counter Medication
1. Written parental/guardian consent for the administration of over-the-counter medication is obtained
through the emergency forms.
2. A record will be maintained every time a medication is given. The record includes the student’s
name, date, time of administration, and dosage.
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020NONPRESCRIPTION MEDICATION PERMIT
PLEASE CHECK those medications you give permission for your child to receive (generic equivalent may be
used).
I/We understand that medications will be administered with discretion by an authorized Program employee
and in accordance with established protocols developed by the Program.
The following nonprescription medications may be available to your child:
For headaches/fever/muscle aches/pain/cramps: Acetaminophen (e.g., Tylenol, including Junior Strength),
Ibuprofen (e.g., Advil, including Children’s liquid, Motrin), Naproxen (Aleve), Midol, & Excedrin.
For bites/allergic rashes: Anti-itching lotion (e.g., Calamine or Hydrocortisone cream 1%), Benadryl liquid
or capsules.
For nasal congestion/sinus pressure: Decongestant
For sore throat: Throat lozenges (e.g., Capitol lozenges) Cough drops/lozenges or cough suppressant.
For upset stomach: Antacid liquid or chewable tablets (e.g., Mylanta)
For sun protection: Sunscreen lotion SPF 30.
I DO NOT WANT ANY MEDICATIONS GIVEN TO MY CHILD.
____________________________________________________ _____________________________
Parent/Guardian Signature Date
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 ______________________________________________________________
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020YOUTH PICK-UP AUTHORIZATION FORM
I authorize the persons listed below to pick-up my child from the Ernestine Mack Clark Miss Delta Doll
Pageant 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).
1. Name_______________________________________________ Relationship________________________
Home Phone __________________Work Phone _________________Cell Phone _____________________
2. Name_______________________________________________ Relationship________________________
Home Phone __________________Work Phone _________________Cell Phone _____________________
3. Name_______________________________________________ Relationship________________________
Home Phone __________________Work Phone _________________Cell Phone _____________________
4. Name_______________________________________________ Relationship________________________
Home Phone __________________Work Phone _________________Cell Phone _____________________
5. 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 Saginaw Alumnae Chapter to release my child to the persons listed above. I also agree to notify
the Saginaw Alumnae Chapter in writing of any changes to the above list of authorized persons.
____________________________________________________ _____________________________
Parent/Guardian Signature Date
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020PARENT WAIVER AND PERMISSION TO TRANSPORT YOUTH
Name of Child:______________________________________________________________________________
I give permission for my child/charge (“child”) to be transported in a motor vehicle driven by the Saginaw
Alumnae Chapter of Delta Sigma Theta Sorority, Inc. and the Ernestine Mack Clark Miss Delta Doll
committee members identified to an event at the specified location on the date indicated. I understand that
my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow
the directions provided by the driver.
I have read, understand, and discussed with my child that:
(1) They will be traveling in a motor vehicle driven by an adult and they are to wear their safety-belt while
traveling;
(2) They are expected to respect the vehicles they ride in, and the person they travel with during the trip;
(3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders,
other drivers, or objects; and
(4) They are to remain in their seats and not be disruptive to the driver of the vehicle.
I recognize that by participating in this activity, as with any activity involving motor vehicle transportation,
my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of
the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any
expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether
I have authorized such expenses.
As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree
to release and forever discharge Delta Sigma Theta Sorority, Incorporated and the Saginaw Alumnae Chapter
from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages,
demands or actions whatsoever, including those based on negligence, in any manner arising out of this
transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally
bound by its terms.
__________________________
Date
____________________________________________
Parent/Guardian Signature
_________________________________________
Print Name
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020OFF-SITE PERMISSION
I/We, (“Parent/Guardian”), as parent(s) or legal guardian(s) of_______________________________ (“Child”),
give permission for my/our Child to participate in the Ernestine Mack Clark Miss Delta Doll Pageant 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 Child by the Chapter.
I/We understand that the field trips are part of the Initiatives and if I/we choose to not 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.
I/We assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips,
except for 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, 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, employees, members, representatives,
agents and assigns.
____________________________________________
Date
____________________________________________
Parent/Guardian Signature
____________________________________________
Print Name
____________________________________________
Date
____________________________________________
Parent/Guardian Signature
____________________________________________
Print Name
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020YOUTH SIGN IN/SIGN OUT POLICY
It is the policy of the Saginaw Alumnae Chapter, Delta Sigma Theta Sorority, Incorporated that all participants
(youth, members, and other volunteers) and visitors must sign in and out of its Ernestine Mack Clark Miss
Delta Doll Pageant Youth Initiative Program (“Program”).
The required sign in/sign out procedures are as follows:
1. The chapter shall maintain and use a sign in log that reflects the following: name of the youth initiative; the
date; the time in and the time out; and the names of the participants, with a column for the participant and
visitors to check her/their status (as member, youth, volunteer, or visitor). The form should distinguish
whether a member is assisting with the Program or is a visitor/observer.
2. Only authorized persons (those identified in writing) will be allowed to pick up a participant from the
Program. Volunteers shall refuse to release a participant to any person, whether related or unrelated to the
youth, who has not been authorized, in writing, by the parent or guardian to receive the youth.
3. One of the following procedures shall be observed during departure and return:
a. Parents or an authorized representative will sign out youth.
b. Older youth who have written parental permission will be allowed to leave the program on their own.
Members will establish a system where the youth check themselves out with an approved volunteer; the
approved volunteer will ensure that the youth signed out and initialed the attendance sheet.
c. When Chapters provide transportation to off-site sponsored events, members will develop and implement a
system to ensure that all youth participating for the day board the correct bus or other vehicle at the time of
departure to and return from a scheduled activity.
4. Failure to pick up your child at the conclusion of a session or activity will result in contact being made with
the local police department and/or child protective services.
5. If a parent or guardian wishes to arrange alternative transportation for their child to attend an off-site
activity, the youth may join the group at the event or activity, but the Saginaw Alumnae Chapter assumes no
responsibility or liability for the youth participant for any non-chapter-sponsored activity or transportation.
____________________________________________________ _____________________________
Parent/Guardian Signature Date
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020PARENTAL/GUARDIAN AFFIRMATION
I, _____________________________________, hereby give my permission to the Saginaw Alumnae Chapter
of Delta Sigma Theta Sorority, Incorporated for my child, ___________________________________ to
participate in the Ernestine Mack Clark Miss Delta Doll Pageant youth initiative (including planned activities),
and I hereby attest, under penalty of perjury, that I have the legal authority to authorize such participation.
____________________________________________________ _____________________________
Parent/Guardian Signature Date
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 (“DST”), 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 Ernestine Mack Clark Miss Delta Doll Youth Initiative.
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 Releases.
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
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020COMMUNITY ACTIVITIES & SERVICE PROJECTS
SELF-DEVELOPMENT ACTIVITIES
PAGEANT REHERSALS & Delta Doll Pictures
A L L D A T E S S U B J E C T T O C H A N G E
REHEARSAL TIMES and DATES
JANUARY Every Thursday, January 9th, 16th, 23rd, 30th. Pageant Rehearsals 6 p.m. – 7:30 p.m.
FEBRUARY Every Thursday, February 6th, 13th, 20th: Pageant Rehearsals 6 p.m. - 7:30 p.m.
MARCH Every Thursday, March 5th, 12th, 19th: Pageant Rehearsals with Escorts 6 p.m. - 7:30 p.m.
APRIL Every Thursday 2ND, 9TH, 16TH: Pageant Opener Rehearsals with Escorts 6 p.m. - 7:30 p.m.
SELF-DEVELOPMENT ACTIVITIES
JANUARY Thursday, January 16, 2020: Tea Party 6:00 pm-7:30pm
FEBRUARY Thursday, February 27, 2020: Umepaint paint experience: 6pm7:30pm
Saturday, February 29, 2020: Beauty Day
APRIL Thursday, April 2, 2020: Love Letter 7:00pm-7:45pm
COMMUNITY AND SERVICE PROJECTS
JANAURY Monday, January 20, 2020: Delta GEM MLK Walk (Community Activity)
FEBRUARY Saturday, February 1, 2020: Feed the Hungry (Service Project)
DELTA DOLL PICTURES
MARCH Thursday, March 26, 2020: Delta Doll Pictures 6:00 p.m. - 7:30 p.m.
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020
Dear Friend/Supporter:
Delta Sigma Theta Sorority Inc., Saginaw Alumnae Chapter (SAC), sponsors an annual Delta
Doll Pageant. The purpose of this pageant is to raise money for the sorority’s Scholarship
Fund. The Scholarships are available to high school seniors who are pursuing higher
education. This pageant allows the sorority to increase the dollar value of those scholarships,
both individually and collectively. The SAC gives out thousands of dollars in scholarships
annually and with your support will continue to do so.
The Miss Ernestine Mack Clark Delta Doll Pageant provides a structured, well-supervised
platform for girls ages 6 -11 to display their talents and abilities. The Delta Doll contestant
that raises the most money will be crowned Miss Delta Doll. All contestants will receive
various prizes and awards for their participation.
A Miss Delta Doll Calendar commemorating this event will be published. We ask that you
support this endeavor by taking a business card ad or being a patron. The prices are:
• Full Page $75.00
• Half Page $50.00
• Quarter Page $25.00
• Eighth Page (Business Card) $10.00
• Patron (price Per Name*) $ 5.00
{example – Mr. and Mrs. Joe and Marth Smith = $5.00 (one name); Mr. and Mrs. Joe and Marth
Smith and Family = $10.00 (two names)
Thank You for your continued support,
The Miss Ernestine Mack Clark Delta Doll Pageant Committee
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Patrons for Doll _______________________________
Name Amount Paid
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Note: Patrons for Souvenir Booklet $5.00 per name*
Mr. and Mrs. Joe and Marth Smith = $5.00 (one name);
Mr. and Mrs. Joe and Marth Smith and Family = $10.00 (two names)
Please complete the following application and submit in person at March 5, 2020 rehearsal or
mail to P. O. Box 2062, Saginaw, MI 48607 by MARCH 5, 2020.
For questions, contact LaNasia C. Hood at (989)274-6595
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020Ernestine Mack Clark Miss Delta Doll Pageant
Delta Sigma Theta Sorority, Inc. - Saginaw Alumnae Chapter
High School Senior Scholarship Program
$10.00
Due: January 30, 2020
Ernestine Mack Clark Miss Delta Doll Parent Workbook and Application |2020You can also read
