Please enable JavaScript in your browser to complete this form. - Step 1 of 15After School Program 2020-2021 Sign Up Form Click Here to Start ASP Sign UpNumber of Parent *One Parent/GuardianTwo Parent/Guardian First Parent/Guardian Information(Primary)PG1 FirstName *Legal First NamePG1 LastName *Legal Last NameAddress: We need a physical address to drop your participants.PG1 PhysicalAddress *Physical Address [Required for Transportation]PG1 MailingAddressMailing AddressPG1 City *CityPG1 State *CaliforniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState (California by default)PG1 ZipCodeZip CodePG1 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthPG1 Gender * MaleFemaleOtherGenderPG1 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusPG1 PlaceOfBirth *Place of BirthPG1 TribalAffiliation *Tribal AffiliationPG1 HighestGrade * InfantHeadstartT-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeCertificateDiplomaSome CollegeAssociatesBachelorMasterDoctorateDegree or Highest Grade AttendedPG1 NameOfSchoolName of School AttendingWe need a method to contact you for any reasonPG1 ContactMethod *Day Phone NumberMobile Phone NumberEvening Phone NumberWork Phone NumberE-Mail( Check all that Apply )Phone Examples(559) 877-72775598777277PG1 DayNumber *Day Phone NumberPG1 MobileNumber *Mobile NumberPG1 EveningNumber *Evening Phone NumberPG1 Work Number *Work Phone NumberPG1 Email *E-MailSecond Parent/Guardian Information(Secondary)PG2 FirstName *Legal First NamePG2 LastName *Legal Last NameIs your address the same as Primary Address?PG2 AddressQuestionYesNoPG1 2 *Physical AddressPG2 MailingAddressMailing AddressPG2 City *CityPG2 State *CaliforniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState (California by default)PG2 ZipCodeZip CodeLiving With Participant?PG2 LivingWithParticipant *YesNoPG2 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthPG2 Gender * MaleFemaleOtherGenderPG2 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusPG2 PlaceOfBirth *Place of BirthPG2 TribalAffiliation *Tribal AffiliationPG2 HighestGrade * InfantHeadstartT-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeCertificateDiplomaSome CollegeAssociatesBachelorMasterDoctorateDegree or Highest Grade AttendedPG2 NameOfSchoolName of School AttendingWe need a method to contact you for any reasonPG2 ContactMethod *Day Phone NumberMobile Phone NumberEvening Phone NumberWork Phone NumberE-Mail( Check all that Apply )Phone Examples(559) 877-72775598777277PG2 DayNumber *Day Phone NumberPG2 MobileNumber *Mobile NumberPG2 EveningNumber *Evening Phone NumberPG2 WorkNumber *Work Phone NumberPG2 Email *E-MailNextInsurance InformationEMG FamilyPhysician *Family Physician NameEMG DrDayPhoneFamily Physician Office Phone NumberEMG DrCellPhoneFamily Physician Cell Phone NumberEMG InsuranceCarrier *Insurance CarrierEMG PolicyPolicy NumberNextPick up and Sign out of After School ProgramIn case the parent/guardian cannot be reached. The Participant will be released to the following Adults 18+Emergancy Contact OneREQUIREDEMG PUSO1Name *First and Last NameEMG PUSO1Phone *Phone NumberEMG PUSO1Cell *Cell Phone NumberEMG PUSO1relationship *Relationship to Participant(s)EMG PUSO1check *Ride Picked up Signed out Check all that applyEMG Add2Click To Add Another Emergency ContactEmergancy Contact TwooptionalEMG PUSOName2First and Last NameEMG PUSOPhone2Phone NumberEMG PUSOCell2Cell Phone NumberEMG PUSORelationship2Relationship to Participant(s)EMG PUSOcheck2Ride Picked up Signed out Check all that applyEMG Add3Click To Add Another Emergency ContactEmergancy Contact ThreeoptionalEMG PUSOName3First and Last NameEMG PUSOPhone3Phone NumberEMG PUSOCell3Cell Phone NumberEMG PUSORelationship3Relationship to Participant(s)EMG PUSOcheck3Ride Picked up Signed out Check all that applyEMG Add4Click To Add Another Emergency ContactEmergancy Contact FouroptionalEMG PUSOName4First and Last NameEMG PUSOPhone4Phone NumberEMG PUSOCell4Cell Phone NumberEMG PUSORelationship4Relationship to Participant(s)EMG PUSOcheck4Ride Picked up Signed out Check all that applyEMG Add5Click To Add Another Emergency ContactEmergancy Contact FiveoptionalEMG PUSOName5First and Last NameEMG PUSOPhone5Phone NumberEMG PUSOCell5Cell Phone NumberEMG PUSORelationship5Relationship to Participant(s)EMG PUSOcheck5Ride Picked up Signed out Check all that applyNextFamily InformationFI1 *1-Parent2-ParentRelative HomeOtherFamily InformationFI TANFQuestion *YesNoTANF Cash Aid?FI1a *Total Number In Household?FI1bNumber of Dependants under 18yrs?NextAt Risk IndicatorsTwo check minimal.(please check all that apply)FI RiskIndicators *Living in high crime rate area Member of low-income family Absent Parent (single parent children) Low academic skills (not low intelligence) Parents are not high school graduates Homelessness / Housing Living with caretaker / relative Substance abuse issues Have negative self-preceptions; low self-esteem Pregnant / Parenting Teen Living on or near Rancheria Lands Domestic violence Previous involvement in Juvenile Justice System Living in unstable school district other FI RiskIndicatorsOther *Reason for OtherNextParticipant(s) InformationParticipant OneP1 FullName *Legal First and Last NameP1 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP1 Gender * MaleFemaleOtherGenderP1 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP1 PlaceOfBirth *Place of BirthP1 TribalAffiliation *Tribal AffiliationP1 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP1 NameOfSchool *Name of School AttendingP1 AllergicReactions *YesNoAllergic ReactionsP1 AllergicReactionYes *Type of AllergiesP1 Asthma *YesNoAsthmaP1 AsthmaReactionYes *Type of Medication TakenP1 Diabetes *YesNoDiabetesP1 DiabetesYes *Type of TreatmentP1 MedicationTakenRegularly *YesNoMedication Taken RegularlyP1 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP1 ListAnyMedsOther Medical ConditionsP1 AddAnotherParticipantAdd Another After School Participant?Participant TwoP2 FullName *Legal First and Last NameP2 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP2 Gender * MaleFemaleOtherGenderP2 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP2 PlaceOfBirth *Place of BirthP2 TribalAffiliation *Tribal AffiliationP2 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP2 NameOfSchool *Name of School AttendingP2 AllergicReactions *YesNoAllergic ReactionsP2 AllergicReactionYes *Type of AllergiesP2 Asthma *YesNoAsthmaP2 AsthmaReactionYes *Type of Medication TakenP2 Diabetes *YesNoDiabetesP2 DiabetesYes *Type of TreatmentP2 MedicationTakenRegularly *YesNoMedication Taken RegularlyP2 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP2 ListAnyMedsOther Medical ConditionsP2 AddAnotherParticipantAdd Another After School Participant?Participant ThreeP3 FullName *Legal First and Last NameP3 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP3 Gender * MaleFemaleOtherGenderP3 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP3 PlaceOfBirth *Place of BirthP3 TribalAffiliation *Tribal AffiliationP3 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP3 NameOfSchool *Name of School AttendingP3 AllergicReactions *YesNoAllergic ReactionsP3 AllergicReactionYes *Type of AllergiesP3 Asthma *YesNoAsthmaP3 AsthmaReactionYes *Type of Medication TakenP3 Diabetes *YesNoDiabetesP3 DiabetesYes *Type of TreatmentP3 MedicationTakenRegularly *YesNoMedication Taken RegularlyP3 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP3 ListAnyMedsOther Medical ConditionsP3 AddAnotherParticipantAdd Another After School Participant?Participant FourP4 FullName *Legal First and Last NameP4 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP4 Gender * MaleFemaleOtherGenderP4 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP4 PlaceOfBirth *Place of BirthP4 TribalAffiliation *Tribal AffiliationP4HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP4 NameOfSchool *Name of School AttendingP4 AllergicReactions *YesNoAllergic ReactionsP4 AllergicReactionYes *Type of AllergiesP4 Asthma *YesNoAsthmaP4 AsthmaReactionYes *Type of Medication TakenP4 Diabetes *YesNoDiabetesP4 DiabetesYes *Type of TreatmentP4 MedicationTakenRegularly *YesNoMedication Taken RegularlyP4 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP4 ListAnyMedsOther Medical ConditionsP4 AddAnotherParticipantAdd Another After School Participant?Participant FiveP5 FullName *Legal First and Last NameP5 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP5 Gender * MaleFemaleOtherGenderP5 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP5 PlaceOfBirth *Place of BirthP5 TribalAffiliation *Tribal AffiliationP5 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP5 NameOfSchool *Name of School AttendingP5 AllergicReactions *YesNoAllergic ReactionsP5AllergicReactionYes *Type of AllergiesP5 Asthma *YesNoAsthmaP5 AsthmaReactionYes *Type of Medication TakenP5 Diabetes *YesNoDiabetesP5 DiabetesYes *Type of TreatmentP5 MedicationTakenRegularly *YesNoMedication Taken RegularlyP5 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP5 ListAnyMedsOther Medical ConditionsP5 AddAnotherParticipantAdd Another After School Participant?Participant SixP6 FullName *Legal First and Last NameP6 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP6 Gender * MaleFemaleOtherGenderP6 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP6 PlaceOfBirth *Place of BirthP6 TribalAffiliation *Tribal AffiliationP6 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP6 NameOfSchool *Name of School AttendingP6 AllergicReactions *YesNoAllergic ReactionsP6 AllergicReactionYes *Type of AllergiesP6 Asthma *YesNoAsthmaP6 AsthmaReactionYes *Type of Medication TakenP6 Diabetes *YesNoDiabetesP6 DiabetesYes *Type of TreatmentP6 MedicationTakenRegularly *YesNoMedication Taken RegularlyP6 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP6 ListAnyMedsOther Medical ConditionsP6 AddAnotherParticipantAdd Another After School Participant?Participant SevenP7 FullName *Legal First and Last NameP7 DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Of BirthP7 Gender * MaleFemaleOtherGenderP7 MaritalStatus *SingleMarriedReMarriedSeparatedDivorcedWidowedMarital StatusP7 PlaceOfBirth *Place of BirthP7 TribalAffiliation *Tribal AffiliationP7 HighestGrade * T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGrade Going IntoP7 NameOfSchool *Name of School AttendingP7 AllergicReactions *YesNoAllergic ReactionsP7 AllergicReactionYes *Type of AllergiesP7 Asthma *YesNoAsthmaP7 AsthmaReactionYes *Type of Medication TakenP7 Diabetes *YesNoDiabetesP7 DiabetesYes *Type of TreatmentP7 MedicationTakenRegularly *YesNoMedication Taken RegularlyP7 MedicationTakenRegularlyYes *List Types of medication, dosage, and scheduleP7 ListAnyMedsOther Medical ConditionsNextPermission SlipI give permission for my children(s) to attend any field trips and/or activities planned by the After School Program. Students will travel in North Fork Rancheria Tribal TANF vehicles driven by The After School Program or other TANF staff.I will notify the staff if my child will not be participating. Please RSVP ASAP! P1 FullName *Legal Parent/Guardian First and Last NameNextTransportation ReleaseI am requesting transportation for my child/children(s) from the North Fork Rancheria Tribal TANF (NFRTT) Family Wellness Youth Center (FWYC) loacated at 56901 Kunugib, North Fork, CA 93643 to my home.Is your Address the same as the Primary Address?ASP TranspRelAddy *YesNoASP TranspRelAddyNO1 *Physical AddressASP TranspRelAddyNO2 *CityASP TranspRelAddyNO3 *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateASP TranspRelAddyNO4 *Zip CodeI understand that I must be present at the time of drop off from the After School Program. No Exceptions. If no parent / legal guardian or person(s) listed on the NFRTT FWYC Program Release is present the child/children will be taken back to NFRTT FWYC where they must be picked up. Future transportation will be jeopardized if child / children are not picked up within 15 minutes of arrival back to the NFRTT FWYC. If child/children are not picked up, the NFRTT FWYC Staff will take appropriate action to provide for the safety and care of the child/children. Please note: North Fork Rancheria Tribal TANF Family Wellness Staff Are Mandated Reporters. ASP TransRelSign *Legal Parent/Guardian First and Last NameNextNorth Fork Rancheria Tribal TANF Family Wellness Youth Center Release of InformationI Give my Permission to North Fork Rancheria Tribal TANF Family Wellness staff to share and/or obtain any academic or behavioral information pertaining to my child/children(s)ASP ReleaseOfInformationSchool *Name of SchoolASP ReleaseOfInformationSig *Legal Parent/Guardian First and Last NameNextInformation Consent and DisclosuresI understand that the services provided at the Family Wellness Youth Center may include the following: Drug and Alcohol Education Tutoring, Reading Computer & Video courses Socialization Skills Cultural Activities Goal Setting Talking Circles/Therapeutic Groups Smoking Prevention & Education Field Trips and outdoor sports (permission for each event will be required from the parent/legal guardian) Abstinence Information, Pregnancy Prevention, and Reproductive Education (age- appropriate) Arts, Crafts, Recreational Activities (may include movies and games) Gang Prevention/li> STD & HIV Education/Prevention (age-appropriate) Computer & Internet Access (monitored) Holiday Events Initial sections that you have read the Following StatementsI authorize the Family Wellness Youth Center staff, volunteers and consultants to assist, teach, inform, and involve participant/child in the above services.ASP InfoConstAndDiscInt1a *Initial HereMy participant/child can participate in all of the services mentioned above.ASP InfoConstAndDiscInt2aInitial HereMy participant/child can participate in all of the services mentioned above except for: ASP InfoConstAndDiscInt3a *Enter all ExceptionsASP InfoConstAndDiscInt3b *Initial HereI give permission to the Family Wellness Youth Center to transport my child for activities as verbally requested by a parent/legal guardian. ASP InfoConstAndDiscInt4a *Initial HereI understand that some or all participant’s/child’s personal information may be shared among the Family Wellness Youth Center professional staff or referral agencies in order to better serve my participant/child.ASP InfoConstAndDiscInt5a *Initial HereI understand I will not be charged for Family Wellness Youth Center services.ASP InfoConstAndDiscInt6a *Initial Here ASP InfoConstAndDiscSig *Legal Parent/Guardian First and Last NameNextAcknowledgment Of RulesI have received and understand the North Fork Rancheria Tribal TANF Family Wellness Youth Center Program for the rules stated and presented to me. No cell phone usage unless in the case of an emergency. - This is so that we may have your full attention No Verbal or physical abuse towards any persons or staff attending Family Wellness Youth Center events is allowed. - Treat people the way that you would want to be treated. No swearing is permitted. - Due to other family members being present we would like to keep it cordial. Please sign in and for all family members in attendance. This is an Alcohol and Drug Free Activity. Disciplinary Action taken if guidelines are not observed (shown below) 1st Participant will be reminded of guidelines. 2nd Participants will be asked to leave for remainder of session/or parents will be contacted. 3rd Participant will be asked to not return for remainder of program. ASP AcknowledgmentOfRulesSig *Legal Parent/Guardian First and Last NameNextNorth Fork Rancheria Tribal TANF Family Wellness Youth CenterThe North Fork Rancheria Tribal TANF Family Wellness Youth Center is a valuable resource center that may be used to conduct job searches, research health related questions and to access academic assistance. To ensure that the computers/ equipment remain in good condition the following guidelines must be followed and agreed upon. Facility Rules All members must sign in upon arrival. Use of staff phones and/or computers, unless authorized, is prohibited. Any person using foul language and/or displaying rude or threatening behavior to other clients or Family Wellness staff will be asked to leave the Family Wellness Youth Center immediately. Family Wellness Youth Center materials (books, videos, etc.) may not be removed from the premises. The Family Wellness Youth Center and staff are not responsible for any lost/misplaced or missing personal items. Computer Use Agreement Use of FWYC computers is limited to: a.) finding employment, i.e., conducting a job search or writing a resume, etc., b) access to the internet to conduct research regarding heath related questions/issues, c) research relating to academic improvement (assignment, academic tutorials, tests, etc.) and to access email accounts of the member. Do not download any sites, programs, games, music, etc. Do not change the settings on computers for any reason No “ADULT CONTENT” websites may be accessed at any time in the NFR Family Wellness Youth Center. Do not use or install CD’s, diskettes unless authorized. No food or drinks may be near or on the computers, equipment, workstations. In the event that there is a waiting list for computer use, members will be limited to 20 minutes of use at a time. Remember to always LOG OFF. No social networking sites (My Space, Facebook, etc.) or chat rooms shall be accessed at any time during use of NFR FWYC computers. Disregarding any of the above guidelines may result in your privileges to the NFR Family Wellness Youth Center being revoked on a temporary or permanent basis. I understand the above and agree to the terms and conditions of utilizing the NFR Family Wellness Youth Center. NFRTTFWYCSig *Legal Parent/Guardian First and Last NameNextRelease and Waiver of Liability Assumption of Risk and Indemnity Agreement (Read Carefully Before Signing)IN CONSIDERATION of participating in activities held at the Family Wellness Youth Center (“FWYC”), a governmental facility owned and operated by the North Fork Rancheria of Mono Indians of California (“Tribe”), a federally recognized Indian tribe, including activities utilizing the use of fitness equipment, a climbing rock wall, bicycles, action sports, and other recreational activities (“Activities”) that may pose risks known or unknown to me, I hereby understand and agree to this release and waiver of liability, assumption of risk and indemnity agreement (“Agreement”) in accordance to the terms hereof as follows:1. I take full responsibility for, and RELEASE AND HOLD HARMLESS FWYC, the Tribe, its officers, elected officials, affiliates, subdivisions, agents and employees (individually or together, the “Released Parties”) from any and all liability, claims, demands or causes of action that I may hereafter have for injuries or damages arising out of my participation in Activities, included, but not limited to, losses caused by the NEGLIGENCE OF THE RELEASED PARTIES or otherwise.RWLARIAInt1 *Initial Here2) I further agree that I WILL NOT SUE OR MAKE CLAIM AGAINST THE RELEASED PARTIES for damages or other losses sustained as a result of any injury, or death, sustained from my participation in Activities. I also agree to INDEMNIFY AND SAVE AND HOLD HARMLESS THE RELEASED PARTIES from all claims, judgments and costs, including attorneys’ fees, incurred in connection with any action brought as a result of participation in Activities by any of the undersigned.RWLARIAInt2 *Initial Here3) I hereby expressly recognize that this Agreement is a contract pursuant to which I have released any and all claims against the Released Parties resulting from any injury, or death, sustained from participation in activities including any claims for negligence of the Released Parties.RWLARIAInt3 *Initial Here4) I acknowledge that the various Activities (as defined above and covered under this Agreement) are subject to mishap and even injury to participants, including the potential for permanent paralysis and death. I understand and acknowledge that such Activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate and I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH OR PERSONAL INJURY OR PROPERTY DAMAGE SUSTAINED WHILE PARTICIPATING IN ACTIVITIES WHETHER OR NOT CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES.RWLARIAInt4 *Initial Here Nothing in this Agreement shall be construed as a waiver, express or implied, of the Tribe’s sovereign immunity from unconsented suits. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND THE TERMS. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND VOLUNTAIRLY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME, AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. RWLARIASigAll1 *Adult Participant Legal First and Last NameRWLARIASigAll2 *Child's Legal Guardian First and Last NameNextPrevention and Photo Liability WaiverIt is understood that I (the participant) cannot participate in the recreation activities until this WAIVER has been completed. I as the legal guardian/parent of the 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 NFRTT. I understand that my participation in the NFRTT activity or my participation in an activity which is being financially sponsored by NFRTT 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 NFRTT 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. NFR 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 Safety is our first priority: If the behavior of an individual is not appropriate, consequences will be determined by the appropriate NFR Tribal TANF staff member. Consequences may include the following: Verbal Warning Parent Contact Sent home from activity at own/parents’ expense Disqualification from future FW prevention events I have read and hereby agree to abide by the NFR Tribal TANF Activity Rules. I further acknowledge that my participation in the NFR 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 NFR 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.PPLPWInt1 *Initial HereI 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 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.PPLPWInt2 *Initial HerePPLPW Sig *Adult Participant Legal First and Last NameWebsiteSubmit