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Fall Festival (NF)

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Fall Festival (NF)

Adult Prevention Form

Event

Program Documents

Pre/Post Test

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The Adult Prevention Form MUST be completed to complete Sign Up.

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Email *

Adult Prevention Form

CIF

Internal use only

Office Location *

Fresno Office
North Fork Office
Mariposa Office
Atascadero Office

First Name *

Last Name *

Phone *

Section 1

Mailing Address

Mailing Address Line 1 *

Mailing Address Line 2

City *

State *

Zip Code *

Section 2

Family Type *

1-Parent
2-Parent
Relative Home
Other

TANF Cash Aid *

List Household Family Members

Total Number In Household? *

Include yourself in the total

Number of Dependents under 18yrs? *

Saved Household Members in Profile

Choice 4
Choice 5
Choice 6
Choice 7
Choice 8
Choice 9
Choice 10
Choice 11
Choice 12
Choice 13

You can select saved household members to fill out the household member information below. You can save up to 10 household members in your account profile.

Household Member 1

For Household Member 1, fill in information for yourself.

Member 1 Name *

First

Last

Member 1 Tribal Affiliation *

Member 1 Gender *

Member 1 Marital Status *

Member 1 Degree or Highest Grade Attended *

Member 1 Date of Birth *

Member 1 Name of School Attending *

Household Member 2

Member 2 Name *

First

Last

Member 2 Tribal Affiliation *

Member 2 Gender *

Member 2 Marital Status *

Member 2 Degree or Highest Grade Attended *

Member 2 Date of Birth *

Member 2 Name of School Attending *

Member 7 List

Household Member 3

Member 3 Name *

First

Last

Member 3 Tribal Affiliation *

Member 3 Gender *

Member 3 Marital Status *

Member 3 Degree or Highest Grade Attended *

Member 3 Date of Birth *

Member 3 Name of School Attending *

Household Member 4

Member 4 Name *

First

Last

Member 4 Tribal Affiliation *

Member 4 Gender *

Member 4 Marital Status *

Member 4 Degree or Highest Grade Attended *

Member 4 Date of Birth *

Member 4 Name of School Attending *

Household Member 5

Member 5 Name *

First

Last

Member 5 Tribal Affiliation *

Member 5 Gender *

Member 5 Marital Status *

Member 5 Degree or Highest Grade Attended *

Member 5 Date of Birth *

Member 5 Name of School Attending *

Household Member 6

Member 6 Name *

First

Last

Member 6 Tribal Affiliation *

Member 6 Gender *

Member 6 Marital Status *

Member 6 Degree or Highest Grade Attended *

Member 6 Date of Birth *

Member 6 Name of School Attending *

Household Member 7

Member 7 Name *

First

Last

Member 7 Tribal Affiliation *

Member 7 Gender *

Member 7 Marital Status *

Member 7 Degree or Highest Grade Attended *

Member 7 Date of Birth *

Member 7 Name of School Attending *

Household Member 8

Member 8 Name *

First

Last

Member 8 Tribal Affiliation *

Member 8 Gender *

Member 8 Marital Status *

Member 8 Degree or Highest Grade Attended *

Member 8 Date of Birth *

Member 8 Name of School Attending *

Household Member 9

Member 9 Name *

First

Last

Member 9 Tribal Affiliation *

Member 9 Gender *

Member 9 Marital Status *

Member 9 Degree or Highest Grade Attended *

Member 9 Date of Birth *

Member 9 Name of School Attending *

Household Member 10

Member 10 Name *

First

Last

Member 10 Tribal Affiliation *

Member 10 Gender *

Member 10 Marital Status *

Member 10 Degree or Highest Grade Attended *

Member 10 Date of Birth *

Member 10 Name of School Attending *

Section 3

At Risk Indicators *

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-perceptions; 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

(please check all that apply)

Other *

Please explain

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.

Signature *

Clear Signature

Date *

Event

 
 
Fall Festival (North Fork)
 
Time: October 23 @ 5:00 pm – October 23 @ 8:00 pm
 
Sign up here!

Program Documents

Pre/Post Test

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