FRE-005-23 Decolonize Your Diet

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Decolonize Your Diet

Servicing the following Counties:
Fresno/Merced Counties & City of Madera

Required

Adult Information

Required
Required
Required (include apt, suite, unit, ect... example 123 any street, apt 1a)
Required
Required
(If no number use all zero) Required
(If no number use all zero) Required
(If no number use all zero) Required
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Required
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Required
(If not attending school use n/a or None) Required

Adult Household Information

Required
Required
Required
Required
Required

Emergency Contact Information

Emergency Contact One
Required
(If no number use all zero) Required
(If no number use all zero) Required
Emergency Contact Two

Insurance Information

Required
Required
Required
(If no number use all zero) Required

At Risk Indicators

Required

Must Include Two Yes
Please Check All That Apply

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Required
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Participants Information

(You are already included, Just enter other Participants/Household members)

Maximum Number of Participants is 7

Participant One

Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish] Required
Required
Required
Required
Required
(if not attending use n/a)
Required

Messaging/Updates

We use a Messaging Services called "Remind" to send any notifications for example: zoom link, reminders, or updates.
If you would like to receive notifications about the event, provide us with a valid Cell Phone Number.
Message and data rates may apply depending on your mobile carrier.
(optional)

E-Mail

We use a Zoom for our presentation and digital communication to contact you.
REQURIED FOR PROGRAM UPDATE OR COMMUNICATION

Terms of Services

The parent(s) of participant(s) must complete and return this agreement. It is understood that I (the participant) cannot participate in the recreation activities until this WAIVER has been completed. As the legal guardian/parent of a minor participant(s), for myself, my personal representative, heirs, next of kin, spouse and assignees do hereby release and discharge the North Fork Rancheria and all of its programs, employees, agents, Board of Directors, and staff from any and all claims and damages, or property damage while participating in the above activity or attending the above activity which is being financially sponsored by North Fork Rancheria Tribal TANF. I understand that my participation in the North Fork Rancheria Tribal TANF activity or my participation in an activity which is being financially sponsored by North Fork Rancheria Tribal TANF may result in potential harm, injury and/or damage to me or my property. In case of an accident or an emergency, I authorize a staff member of North Fork Rancheria Tribal TANF to take my child to the above-named Physician or to the nearest Emergency Hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child at my expense. All allergic reactions to and current medication-taking information must be disclosed on this form.

I have read and hereby agree to abide by the North Fork Rancheria Tribal TANF Activity Rules. I further acknowledge that my participation in the North Fork Rancheria Tribal TANF Activities will be in jeopardy should I fail to adhere to the rules. I give permission for any photos/filming of my child/myself taken while participating in this activity, to be used by North Fork Rancheria and its programs for promotional use, such as but not limited to: newspaper, television, posters, social media, magazines, promotional or educational, etc. I also understand that I will not receive any compensation for such use.

Safety is our first priority. If the behavior of an individual is not appropriate, consequences will be determined by the appropriate North Fork Rancheria Tribal TANF staff member.

North Fork Rancheria Tribal TANF – Code of Conduct: Be helpful, courteous, and respectful to others at all times

Do not use or possess alcohol, tobacco, or other drugs. Check-in with your event leaders, so they know where you are at, at all times. Be respectful of other youth (No fighting, pushing, hitting, or “put-downs”). Be respectful of the environment (No littering or vandalism). No vulgar language will be tolerated. NO PETS ALLOWED

Consequences may include the following: Verbal Warning, Parent Contact, Sent home from an activity at own/parents’ expense, Disqualification from future FW prevention events

I certify that all information reported in this application is accurate to the best of my knowledge and hereby authorize the information to be used by the North Fork Rancheria Tribal TANF Program, for the purpose of Data Tracking. Disclaimer: I understand that my information is confidential and will not be divulged to anyone without my permission.

Electronic Signature Agreement.
By clicking the “Submit” button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By clicking “Submit” you consent to be legally bound by this Agreement's terms and conditions (hereafter referred to as "E-Signature"). You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to enter into this Agreement for all persons who are in this agreement will be bound by the terms of this Agreement. You further agree that each use of your E-Signature constitutes your agreement to be bound by the terms and conditions of the North Fork Rancheria Tribal TANF.

BY TYPING MY SIGNATURE, I ACKNOWLEDGE THAT I FULLY UNDERSTAND AND AGREE WITH THE TERMS AND CONDITIONS STATED ABOVE.