Sign Up Adult Prevention Form Youth Prevention Form Event Flyer Program Documents Pre/Post Test Sign Up Sign UpThe Adult Prevention and Youth Prevention Forms MUST be completed to complete Sign Up.Please 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.Choose Your Service Area Location *Fresno CountyMadera CountyMariposa CountyMerced CountyAdult InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDay Phone *If you do not wish to provide a number, use (559)877-7277Evening Phone *If you do not wish to provide a number, use (559)877-7277Mobile Phone *If you do not wish to provide a number, use (559)877-7277Would you like to receive Text Messages from us? *YesNoWe use a Messaging service to send out notifications such as Zoom links, reminders, and updates.Message and data rates may apply depending on your mobile carrier.Email Address *We use Zoom for our presentations.Please provide your email 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 Mobile PhoneEmergency Contact 2Emergency Contact 2 Name *FirstLastEmergency Contact 2 Phone *Emergency Contact 2 Mobile PhoneInsurance InformationInsurance Carrier *Family Physician *Policy # *Physician Phone *Participation Information ***All participants must be listed prior to attendance.*** You are already included. This is for participants other than yourself. Would you like to add a Participant? *YesNoParticipant 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? *YesNoParticipant 2Participant 2 Name *FirstLastParticipant 2 Age *Participant 2 Grade *Participant 2 Gender *FemaleMaleOtherParticipant 2 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 3rd Participant? *YesNoParticipant 3Participant 3 Name *FirstLastParticipant 3 Age *Participant 3 Grade *Participant 3 Gender *FemaleMaleOtherParticipant 3 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 4th Participant? *YesNoParticipant 4Participant 4 Name *FirstLastParticipant 4 Age *Participant 4 Grade *Participant 4 Gender *FemaleMaleOtherParticipant 4 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 5th Participant? *YesNoParticipant 5Participant 5 Name *FirstLastParticipant 5 Age *Participant 5 Grade *Participant 5 Gender *FemaleMaleOtherParticipant 5 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 6th Participant? *YesNoParticipant 6Participant 6 Name *FirstLastParticipant 6 Age *Participant 6 Grade *Participant 6 Gender *FemaleMaleOtherParticipant 6 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add a 7th Participant? *YesNoParticipant 7Participant 7 Name *FirstLastParticipant 7 Age *Participant 7 Grade *Participant 7 Gender *FemaleMaleOtherParticipant 7 Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Would you like to add an 8th Participant? *YesNoParticipant 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 Adult Prevention Form Adult Prevention FormPlease enable JavaScript in your browser to complete this form.CIFInternal use onlyService Area *Fresno CountyMadera CountyMariposa CountyMonterey CountySan Benito CountySan Luis Obispo CountyName *FirstLastPhone *Section 1Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSection 2Family Type *1-Parent2-ParentRelative HomeOtherTANF Cash Aid *YesNoTotal Number In Household? *Include yourself in the totalNumber of Dependents under 18yrs? *List Household Family MembersHousehold Member 1For Household Member 1, fill in information for yourself.Member 1 Name *FirstLastMember 1 Tribal Affiliation *Member 1 Gender *FemaleFemaleMaleOtherMember 1 Marital StatusMember 1 Degree or Highest Grade Attended *Member 1 Date of Birth *Member 1 Name of School Attending *Add Household Member 2? *YesHousehold Member 2Member 2 Name *FirstLastMember 2 Tribal Affiliation *Member 2 Gender *FemaleMaleOtherMember 2 Marital Status *Member 2 Degree or Highest Grade Attended *Member 2 Date of Birth *Member 2 Name of School Attending *Add Household Member 3? *YesHousehold Member 3Member 3 Name *FirstLastMember 3 Tribal Affiliation *Member 3 Gender *FemaleMaleOtherMember 3 Marital Status *Member 3 Degree or Highest Grade Attended *Member 3 Date of Birth *Member 3 Name of School Attending *Add Household Member 4? *YesHousehold Member 4Member 4 Name *FirstLastMember 4 Tribal Affiliation *Member 4 Gender *FemaleMaleOtherMember 4 Marital Status *Member 4 Degree or Highest Grade Attended *Member 4 Date of Birth *Member 4 Name of School Attending *Add Household Member 5? *YesHousehold Member 5Member 5 Name *FirstLastMember 5 Tribal Affiliation *Member 5 Gender *FemaleMaleOtherMember 5 Marital Status *Member 5 Degree or Highest Grade Attended *Member 5 Date of Birth *Member 5 Name of School Attending *Add Household Member 6? *YesHousehold Member 6Member 6 Name *FirstLastMember 6 Tribal Affiliation *Member 6 Gender *FemaleMaleOtherMember 6 Marital Status *Member 6 Degree or Highest Grade Attended *Member 6 Date of Birth *Member 6 Name of School Attending *Add Household Member 7? *YesHousehold Member 7Member 7 Name *FirstLastMember 7 Tribal Affiliation *Member 7 Gender *FemaleMaleOtherMember 7 Marital Status *Member 7 Degree or Highest Grade Attended *Member 7 Date of Birth *Member 7 Name of School Attending *Add Household Member 8? *YesHousehold Member 8Member 8 Name *FirstLastMember 8 Tribal Affiliation *Member 8 Gender *FemaleMaleOtherMember 8 Marital Status *Member 8 Degree or Highest Grade Attended *Member 8 Date of Birth *Member 8 Name of School Attending *Add Household Member 9? *YesHousehold Member 9Member 9 Name *FirstLastMember 9 Tribal Affiliation *Member 9 Gender *FemaleMaleOtherMember 9 Marital Status *Member 9 Degree or Highest Grade Attended *Member 9 Date of Birth *Member 9 Name of School Attending *Add Household Member 10? *YesHousehold Member 10Member 10 Name *FirstLastMember 10 Tribal Affiliation *Member 10 Gender *FemaleMaleOtherMember 10 Marital Status *Member 10 Degree or Highest Grade Attended *Member 10 Date of Birth *Member 10 Name of School Attending *Section 3At Risk Indicators *Living in high crime rate areaMember of low-income familyAbsent parent (single parent children)Low academic skills (not low intelligence)Parents are not high school graduatesHomelessness /housingLiving with caretaker /relativeSubstance abuse issuesHave negative self-perceptions; low self-esteemPregnant /Parenting teenLiving on or near Rancheria landsDomestic violencePrevious involvement in Juvenile Justice SystemLiving in unstable school districtOther(please check all that apply)OtherPlease explainI 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 SignatureDate *Submit Youth Prevention Form Youth Prevention Form Please enable JavaScript in your browser to complete this form.CIFInternal use onlyService Area *Fresno CountyMadera CountyMariposa CountyMonterey CountySan Benito CountySan Luis Obispo CountySection 1 Student InformationName *FirstLastMailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysical Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTribal AffiliationSchool AttendingAge121314151617Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian #1 Name *FirstLastParent/Guardian #2 Name *FirstLastPhone *Message Phone (if different) *Section 2 Risk Factors for ServicesHave you ever experimented with drugs? *YesNoHave you ever been exposed to alcohol or drugs? *YesNoHow often are you exposed to alcohol or drugs? *DailyOtherIf other, how often? *Have you ever felt peer pressure to have sex? *YesNoAre you sexually active? *YesNoHave you ever been exposed to violence? (Physical or Verbal) *YesNoHave you ever been in an altercation /fight? *YesNoHave you ever been suspended from school? *YesNoHave you ever been arrested? *YesNoDo you live with your parents? *YesNoAre your parents married? *YesNoDo you currently have a “C” average (2.0 gpa)? *YesNoDo you consider yourself a risk taker? *YesNoHave you experienced the loss of a family member or friend? *YesNoDo you live on the Rancheria? *YesNoDo you feel safe in your community? *YesNoIn your opinion, do many kids in your community, under 18 yrs use alcohol and drugs? *YesNoSection 3Specify Activities that would interest you? *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, including my parents.Signature *Clear SignatureDate *Submit Event Harvest Moon Mariposa Time: November 17 @ 6:00 pm – November 17 @ 7:30 pm Sign up for this event here: https://nfrfamily.org/programs/harvest-moon-mariposa/ Flyer Program Documents Pre/Post Test Pre/Post Test