SIGN UP – NFR Family Wellness

- Step 1 of 15

After School Program 2020-2021 Sign Up Form

Number of Parent *

One Parent/Guardian
Two Parent/Guardian

First Parent/Guardian Information

(Primary)

PG1 FirstName *

Legal First Name

PG1 LastName *

Legal Last Name

Address: We need a physical address to drop your participants.

PG1 PhysicalAddress *

Physical Address [Required for Transportation]

PG1 MailingAddress

Mailing Address

PG1 City *

City

PG1 State *

State (California by default)

PG1 ZipCode

Zip Code

PG1 DOB *//

Date Of Birth

PG1 Gender *

Gender

PG1 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

PG1 PlaceOfBirth *

Place of Birth

PG1 TribalAffiliation *

Tribal Affiliation

PG1 HighestGrade *

Degree or Highest Grade Attended

PG1 NameOfSchool

Name of School Attending

We need a method to contact you for any reason

PG1 ContactMethod *

Day Phone Number
Mobile Phone Number
Evening Phone Number
Work Phone Number
E-Mail

( Check all that Apply )

Phone Examples

(559) 877-7277
5598777277

PG1 DayNumber *

Day Phone Number

PG1 MobileNumber *

Mobile Number

PG1 EveningNumber *

Evening Phone Number

PG1 Work Number *

Work Phone Number

PG1 Email *

E-Mail

Second Parent/Guardian Information

(Secondary)

PG2 FirstName *

Legal First Name

PG2 LastName *

Legal Last Name

Is your address the same as Primary Address?

PG2 AddressQuestion

PG1 2 *

Physical Address

PG2 MailingAddress

Mailing Address

PG2 City *

City

PG2 State *

State (California by default)

PG2 ZipCode

Zip Code

Living With Participant?

PG2 LivingWithParticipant *

PG2 DOB *//

Date Of Birth

PG2 Gender *

Gender

PG2 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

PG2 PlaceOfBirth *

Place of Birth

PG2 TribalAffiliation *

Tribal Affiliation

PG2 HighestGrade *

Degree or Highest Grade Attended

PG2 NameOfSchool

Name of School Attending

We need a method to contact you for any reason

PG2 ContactMethod *

Day Phone Number
Mobile Phone Number
Evening Phone Number
Work Phone Number
E-Mail

( Check all that Apply )

Phone Examples

(559) 877-7277
5598777277

PG2 DayNumber *

Day Phone Number

PG2 MobileNumber *

Mobile Number

PG2 EveningNumber *

Evening Phone Number

PG2 WorkNumber *

Work Phone Number

PG2 Email *

E-Mail

Insurance Information

EMG FamilyPhysician *

Family Physician Name

EMG DrDayPhone

Family Physician Office Phone Number

EMG DrCellPhone

Family Physician Cell Phone Number

EMG InsuranceCarrier *

Insurance Carrier

EMG Policy

Policy Number

Pick up and Sign out of After School Program
In case the parent/guardian cannot be reached. The Participant will be released to the following Adults 18+

Emergancy Contact One

REQUIRED

EMG PUSO1Name *

First and Last Name

EMG PUSO1Phone *

Phone Number

EMG PUSO1Cell *

Cell Phone Number

EMG PUSO1relationship *

Relationship to Participant(s)

EMG PUSO1check *

Ride
Picked up
Signed out

Check all that apply

EMG Add2

Click To Add Another Emergency Contact

Emergancy Contact Two

optional

EMG PUSOName2

First and Last Name

EMG PUSOPhone2

Phone Number

EMG PUSOCell2

Cell Phone Number

EMG PUSORelationship2

Relationship to Participant(s)

EMG PUSOcheck2

Ride
Picked up
Signed out

Check all that apply

EMG Add3

Click To Add Another Emergency Contact

Emergancy Contact Three

optional

EMG PUSOName3

First and Last Name

EMG PUSOPhone3

Phone Number

EMG PUSOCell3

Cell Phone Number

EMG PUSORelationship3

Relationship to Participant(s)

EMG PUSOcheck3

Ride
Picked up
Signed out

Check all that apply

EMG Add4

Click To Add Another Emergency Contact

Emergancy Contact Four

optional

EMG PUSOName4

First and Last Name

EMG PUSOPhone4

Phone Number

EMG PUSOCell4

Cell Phone Number

EMG PUSORelationship4

Relationship to Participant(s)

EMG PUSOcheck4

Ride
Picked up
Signed out

Check all that apply

EMG Add5

Click To Add Another Emergency Contact

Emergancy Contact Five

optional

EMG PUSOName5

First and Last Name

EMG PUSOPhone5

Phone Number

EMG PUSOCell5

Cell Phone Number

EMG PUSORelationship5

Relationship to Participant(s)

EMG PUSOcheck5

Ride
Picked up
Signed out

Check all that apply

Family Information

FI1 *

1-Parent
2-Parent
Relative Home
Other

Family Information

FI TANFQuestion *

TANF Cash Aid?

FI1a *

Total Number In Household?

FI1b

Number of Dependants under 18yrs?

At 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 Other

Participant(s) Information

Participant One

P1 FullName *

Legal First and Last Name

P1 DOB *//

Date Of Birth

P1 Gender *

Gender

P1 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P1 PlaceOfBirth *

Place of Birth

P1 TribalAffiliation *

Tribal Affiliation

P1 HighestGrade *

Grade Going Into

P1 NameOfSchool *

Name of School Attending

P1 AllergicReactions *

Allergic Reactions

P1 AllergicReactionYes *

Type of Allergies

P1 Asthma *

Asthma

P1 AsthmaReactionYes *

Type of Medication Taken

P1 Diabetes *

Diabetes

P1 DiabetesYes *

Type of Treatment

P1 MedicationTakenRegularly *

Medication Taken Regularly

P1 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P1 ListAnyMeds

Other Medical Conditions

P1 AddAnotherParticipant

Add Another After School Participant?

Participant Two

P2 FullName *

Legal First and Last Name

P2 DOB *//

Date Of Birth

P2 Gender *

Gender

P2 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P2 PlaceOfBirth *

Place of Birth

P2 TribalAffiliation *

Tribal Affiliation

P2 HighestGrade *

Grade Going Into

P2 NameOfSchool *

Name of School Attending

P2 AllergicReactions *

Allergic Reactions

P2 AllergicReactionYes *

Type of Allergies

P2 Asthma *

Asthma

P2 AsthmaReactionYes *

Type of Medication Taken

P2 Diabetes *

Diabetes

P2 DiabetesYes *

Type of Treatment

P2 MedicationTakenRegularly *

Medication Taken Regularly

P2 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P2 ListAnyMeds

Other Medical Conditions

P2 AddAnotherParticipant

Add Another After School Participant?

Participant Three

P3 FullName *

Legal First and Last Name

P3 DOB *//

Date Of Birth

P3 Gender *

Gender

P3 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P3 PlaceOfBirth *

Place of Birth

P3 TribalAffiliation *

Tribal Affiliation

P3 HighestGrade *

Grade Going Into

P3 NameOfSchool *

Name of School Attending

P3 AllergicReactions *

Allergic Reactions

P3 AllergicReactionYes *

Type of Allergies

P3 Asthma *

Asthma

P3 AsthmaReactionYes *

Type of Medication Taken

P3 Diabetes *

Diabetes

P3 DiabetesYes *

Type of Treatment

P3 MedicationTakenRegularly *

Medication Taken Regularly

P3 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P3 ListAnyMeds

Other Medical Conditions

P3 AddAnotherParticipant

Add Another After School Participant?

Participant Four

P4 FullName *

Legal First and Last Name

P4 DOB *//

Date Of Birth

P4 Gender *

Gender

P4 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P4 PlaceOfBirth *

Place of Birth

P4 TribalAffiliation *

Tribal Affiliation

P4HighestGrade *

Grade Going Into

P4 NameOfSchool *

Name of School Attending

P4 AllergicReactions *

Allergic Reactions

P4 AllergicReactionYes *

Type of Allergies

P4 Asthma *

Asthma

P4 AsthmaReactionYes *

Type of Medication Taken

P4 Diabetes *

Diabetes

P4 DiabetesYes *

Type of Treatment

P4 MedicationTakenRegularly *

Medication Taken Regularly

P4 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P4 ListAnyMeds

Other Medical Conditions

P4 AddAnotherParticipant

Add Another After School Participant?

Participant Five

P5 FullName *

Legal First and Last Name

P5 DOB *//

Date Of Birth

P5 Gender *

Gender

P5 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P5 PlaceOfBirth *

Place of Birth

P5 TribalAffiliation *

Tribal Affiliation

P5 HighestGrade *

Grade Going Into

P5 NameOfSchool *

Name of School Attending

P5 AllergicReactions *

Allergic Reactions

P5AllergicReactionYes *

Type of Allergies

P5 Asthma *

Asthma

P5 AsthmaReactionYes *

Type of Medication Taken

P5 Diabetes *

Diabetes

P5 DiabetesYes *

Type of Treatment

P5 MedicationTakenRegularly *

Medication Taken Regularly

P5 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P5 ListAnyMeds

Other Medical Conditions

P5 AddAnotherParticipant

Add Another After School Participant?

Participant Six

P6 FullName *

Legal First and Last Name

P6 DOB *//

Date Of Birth

P6 Gender *

Gender

P6 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P6 PlaceOfBirth *

Place of Birth

P6 TribalAffiliation *

Tribal Affiliation

P6 HighestGrade *

Grade Going Into

P6 NameOfSchool *

Name of School Attending

P6 AllergicReactions *

Allergic Reactions

P6 AllergicReactionYes *

Type of Allergies

P6 Asthma *

Asthma

P6 AsthmaReactionYes *

Type of Medication Taken

P6 Diabetes *

Diabetes

P6 DiabetesYes *

Type of Treatment

P6 MedicationTakenRegularly *

Medication Taken Regularly

P6 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P6 ListAnyMeds

Other Medical Conditions

P6 AddAnotherParticipant

Add Another After School Participant?

Participant Seven

P7 FullName *

Legal First and Last Name

P7 DOB *//

Date Of Birth

P7 Gender *

Gender

P7 MaritalStatus *

Single
Married
ReMarried
Separated
Divorced
Widowed

Marital Status

P7 PlaceOfBirth *

Place of Birth

P7 TribalAffiliation *

Tribal Affiliation

P7 HighestGrade *

Grade Going Into

P7 NameOfSchool *

Name of School Attending

P7 AllergicReactions *

Allergic Reactions

P7 AllergicReactionYes *

Type of Allergies

P7 Asthma *

Asthma

P7 AsthmaReactionYes *

Type of Medication Taken

P7 Diabetes *

Diabetes

P7 DiabetesYes *

Type of Treatment

P7 MedicationTakenRegularly *

Medication Taken Regularly

P7 MedicationTakenRegularlyYes *

List Types of medication, dosage, and schedule

P7 ListAnyMeds

Other Medical Conditions

Permission Slip

I 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 Name

Transportation Release

I 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 *

ASP TranspRelAddyNO1 *

Physical Address

ASP TranspRelAddyNO2 *

City

ASP TranspRelAddyNO3 *

State

ASP TranspRelAddyNO4 *

Zip Code

I 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 Name

North Fork Rancheria Tribal TANF Family Wellness Youth Center Release of Information

I 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 School

ASP ReleaseOfInformationSig *

Legal Parent/Guardian First and Last Name

Information Consent and Disclosures

I 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 Statements

I 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 Here

My participant/child can participate in all of the services mentioned above.

ASP InfoConstAndDiscInt2a

Initial Here

My participant/child can participate in all of the services mentioned above except for:

ASP InfoConstAndDiscInt3a *

Enter all Exceptions

ASP InfoConstAndDiscInt3b *

Initial Here

I 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 Here

I 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 Here

I understand I will not be charged for Family Wellness Youth Center services.

ASP InfoConstAndDiscInt6a *

Initial Here

ASP InfoConstAndDiscSig *

Legal Parent/Guardian First and Last Name

Acknowledgment Of Rules

I 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 Name

North Fork Rancheria Tribal TANF Family Wellness Youth Center

The 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 Name

Release and Waiver of LiabilityAssumption 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 Here

2) 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 Here

3) 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 Here

4) 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 Name

RWLARIASigAll2 *

Child's Legal Guardian First and Last Name

Prevention and Photo Liability Waiver

It 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 Here

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 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 Here

PPLPW Sig *

Adult Participant Legal First and Last Name

Name