GONA 2023 – NFR Family Wellness

Adult Information

Adult Legal First Name: *

Required

Adult Legal Last Name: *

Required

Physical Address: *

Required (include apt, suite, unit, ect… example 123 any street, apt 1a)

City: *

Required

Zip Code *

Required

Evening Phone Number: *

(If no number use all zero) Required

Mobile Phone Number *

(If no number use all zero) Required

Day Phone Number: *

(If no number use all zero) Required

Date of Birth *

Required

Gender *

Required

Place of Birth: *

Required

Tribal Affiliation *

example: (North Fork Rancheria Mono, Chukchansi, Big Sandy, Tachi, None, n/a) [you can add more than one tribe if you wish] Required

Degree or Highest Grade Attended *

Required

Name of School Attending *

(If not attending school use n/a or None) Required

Adult Household Information

Family Type *

1-Parent
2-Parent
Relative Home
Other

Required

TANF Cash Aid *

Required

Total Number of Dependants under 18 yrs old *

Required

Total Number In Household *

Required

Emergency Contact Information

Emergency Contact One

Full Name *

Required

Phone Number *

(If no number use all zero) Required

Cell Phone Number *

(If no number use all zero) Required

Emergency Contact Two

Name

Phone Number

Cell Phone Number

Insurance Information

Insurance Carrier *

Required

Policy Number *

Required

Family Physician Name *

Required

Physician Phone Number *

(If no number use all zero) Required

At Risk Indicators

Required

Must Include Two Yes
Please Check All That Apply

Living in high crime rate area *

Required

Member of low-income family *

Required

Absent parent (single parent children) *

Required

Low academic skills (not low intelligence) *

Required

Parents are not high school graduates *

Required

Homelessness / housing *

Required

Living with caretaker / relative *

Required

Substance abuse issues *

Required

Have negative self-preceptions; low self-esteem *

Required

Pregnant / parenting teen *

Required

Living on or near Rancheria lands *

Required

Domestic violence *

Required

Previous Involvement in Juvenile Justice System *

Required

Living in unstable school district *

Required

Other

Participants Information

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

Maximum Number of Participants is 7

Participant One

Legal First and Last Name *

Required

Tribal Affiliation *

example: (North Fork Rancheria Mono, Chukchansi, Big Sandy, Tachi, None, n/a) [you can add more than one tribe if you wish] Required

Date of Birth *

Required

Gender *

Required

Highest Grade/Degree *

Required

Name of School Attending *

(if not attending use n/a)
Required

Add Participant Two?

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.

Cell/Mobile Phone Number

(optional)

E-Mail

We use a Zoom for our presentation and digital communication to contact you.

E-Mail Address *

REQURIED FOR PROGRAM UPDATE OR COMMUNICATION

Terms of Services

I Agree with the following Terms

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.

Sign Up

Adult Information

Adult Household Information

Emergency Contact Information

Insurance Information

At Risk Indicators

Participants Information

Participant One

Participant Two

Participant Three

Participant Four

Participant Five

Participant Six

Participant Seven

Messaging/Updates

E-Mail

Terms of Services

Pre/Post Test