Sign Up Event Flyer Program Documents Pre/Post Test Sign Up Sign UpHave you filled out the Adult Prevention Application? If not, please do so (and fill out the form below) to complete Sign Up.Please enable JavaScript in your browser to complete this form.CIF *Internal use onlyChoose Your Service Area Location *Fresno CountyMadera CountyMariposa CountyAdult InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDay Phone *(If no number use all zero)Evening Phone *(If no number use all zero)Mobile Phone *(If no number use all zero)Would you like to receive Text Messages from us? *YesNoWe use a Messaging service to send out notifications such as zoom links, reminders, or updates.Message and data rates may apply depending on your mobile carrier.Email Address *We use Zoom for our presentations.Please proved your E-Mail address so we can send you the Zoom Login Information.Place of Birth *Birthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Emergency Contact InformationEmergency Contact 1Emergency Contact 1 Name *FirstLastEmergency Contact 1 Phone *Emergency Contact 1 Moible PhoneEmergency Contact 2Emergency Contact 2 Name *FirstLastEmergency Contact 2 Phone *Emergency Contact 2 Moible PhoneInsurance InformationInsurance Carrier *Family Physician *Policy # *Physician Phone *Participation InformationWould You like to add a Participant(s)?YesYou are already included. This is for participants other than yourself.Participant 1Participant 1 Name *FirstLastParticipant 1 Age *Participant 1 Grade *Participant 1 Gender *FemaleMaleOtherParticipant 1 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 2nd Participant?YesParticipant 2Participant 2 Name *FirstLastParticipant 2 Age *Participant 2 Grade *Participant 2 Gender *FemaleMaleOtherParticipant 2 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 3rd Participant?YesParticipant 3Participant 3 Name *FirstLastParticipant 3 Age *Participant 3 Grade *Participant 3 Gender *FemaleMaleOtherParticipant 3 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 4th Participant?YesParticipant 4Participant 4 Name *FirstLastParticipant 4 Age *Participant 4 Grade *Participant 4 Gender *FemaleMaleOtherParticipant 4 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 5th Participant?YesParticipant 5Participant 5 Name *FirstLastParticipant 5 Age *Participant 5 Grade *Participant 5 Gender *FemaleMaleOtherParticipant 5 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 6th Participant?YesParticipant 6Participant 6 Name *FirstLastParticipant 6 Age *Participant 6 Grade *Participant 6 Gender *FemaleMaleOtherParticipant 6 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 7th Participant?YesParticipant 7Participant 7 Name *FirstLastParticipant 7 Age *Participant 7 Grade *Participant 7 Gender *FemaleMaleOtherParticipant 7 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add 8th Participant?YesParticipant 8Participant 8 Name *FirstLastParticipant 8 Age *Participant 8 Grade *Participant 8 Gender *FemaleMaleOtherParticipant 8 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Allergy Information DiscloserAll allergic reactions to, and current medication taking information must be disclosedAgreementThe 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. I, (the adult listed above), as the legal guardian/parent of (see above) 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 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 in the Allergy Information Discloser field above. 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 prevention events I have read and hereby agree to abide by the NFR Tribal TANF Recreation Activity Rules. I further acknowledge that my participation in the NFR Tribal TANF Recreation 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, internet, magazines, promotional or educational, etc. I also understand that I will not receive any compensation for such use. Electronic Signature Agreement. By submitting this form and using the electronic signature field below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By submitting this form, 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 SIGNING ELECTRONICALLY, I ACKNOWLEDGE THAT I FULLY UNDERSTAND AND AGREE WITH THE TERMS AND CONDITIONS STATED ABOVE. PARTICIPANT’S/PARENT’S SIGNATURE: *Clear Signature (Parent or legal guardian must sign for those under 18 years of age) Date *Submit Event Family Night North Fork Time: June 15 @ 5:30 pm – June 15 @ 7:30 pm Sign up Here Flyer FN Flyer 2_Chelsea Rogozienski Program Documents EvaluationPlease enable JavaScript in your browser to complete this form.Name *FirstLast1. * PoorFairGoodExcellent Please rate the presenter(s) based on the following: style, pace delivery, instruction skills, etc.?PoorPlease rate the presenter(s) based on the following: style, pace delivery, instruction skills, etc.? PoorFairPlease rate the presenter(s) based on the following: style, pace delivery, instruction skills, etc.? FairGoodPlease rate the presenter(s) based on the following: style, pace delivery, instruction skills, etc.? GoodExcellentPlease rate the presenter(s) based on the following: style, pace delivery, instruction skills, etc.? Excellent 1. Comments2. * PoorFairGoodExcellent Please rate the training materials/handouts used in this presentation?PoorPlease rate the training materials/handouts used in this presentation? PoorFairPlease rate the training materials/handouts used in this presentation? FairGoodPlease rate the training materials/handouts used in this presentation? GoodExcellentPlease rate the training materials/handouts used in this presentation? Excellent 2. Comments3. * PoorFairGoodExcellent Please rate the facilities and location where this program was held (space and layout of room, equipment, adequacy of parking, personal comfort or room)?PoorPlease rate the facilities and location where this program was held (space and layout of room, equipment, adequacy of parking, personal comfort or room)? PoorFairPlease rate the facilities and location where this program was held (space and layout of room, equipment, adequacy of parking, personal comfort or room)? FairGoodPlease rate the facilities and location where this program was held (space and layout of room, equipment, adequacy of parking, personal comfort or room)? GoodExcellentPlease rate the facilities and location where this program was held (space and layout of room, equipment, adequacy of parking, personal comfort or room)? Excellent 3. Comments4. * PoorFairGoodExcellent Overall, how would you rate the program?PoorOverall, how would you rate the program? PoorFairOverall, how would you rate the program? FairGoodOverall, how would you rate the program? GoodExcellentOverall, how would you rate the program? Excellent 4. CommentsWould you recommend the program to others? Explain something you took away from the program? Do you have any suggestions for improvement? Submit Pre/Post Test Pre/Post TestPre-TestPlease enable JavaScript in your browser to complete this form.CIF *Internal use only. This field is disabled for input. The field will auto-populate if signed-in otherwise you will see a dash.Name *FirstLast1. What is family time? *A. All forms of communication of family membersB. Family members being in a general area togetherC. Being at home2. What does quality family time mean? *A. Dedicated time to the whole family doing activities as a familyB. Increasing communicationC. Creating a stronger bond3. Why is family time meaningful? *A. It helps construct principlesB. Improves overall mental, emotional, physical, and spiritual healthC. All of the Above4. What are examples of quality time with family? *A. Share chores, going on outings, travelingB. Eating family meals, creating memoriesC. All of the Above5. What are some distractions from family time? *TV’sCellphonesComputers, Video GamesSocial MediaAll of the Above6. Family time is crucial and beneficial. True or False? *TrueFalseSubmit Post-TestPlease enable JavaScript in your browser to complete this form.CIF *Internal use only. This field is disabled for input. The field will auto-populate if signed-in otherwise you will see a dash.Name *FirstLast1. What is family time? *A. All forms of communication of family membersB. Family members being in a general area togetherC. Being at home2. What does quality family time mean? *A. Dedicated time to the whole family doing activities as a familyB. Increasing communicationC. Creating a stronger bond3. Why is family time meaningful? *A. It helps construct principlesB. Improves overall mental, emotional, physical, and spiritual healthC. All of the Above4. What are examples of quality time with family? *A. Share chores, going on outings, travelingB. Eating family meals, creating memoriesC. All of the Above5. What are some distractions from family time? *TV’sCellphonesComputers, Video GamesSocial MediaAll of the Above6. Family time is crucial and beneficial. True or False? *TrueFalseSubmit