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Family Wellness
About Family Wellness
Atascadero Team
Fresno Team
North Fork Team
Employment
Programs
A Taste of Native American Culture
Career Development
Changes of the Season
Sign up for Changes of the Season
Pre and Post Test
Balance Activity Sheet
Human Nature Poem
Native Reflection Work Sheet
Decolonize Your Diet
Educational Pathways
Family Night
Futures Without Violence
Hand Drum Making
Mariposa Location
North Fork Location
Honoring Ancestral Foodways
Indigenous Mothers Talking Circle
Johnson O’Malley Program
Resilience
Fresno Office
Atascadero Office
Summer Work Experience 2023
Atascadero Office
Fresno Office
North Fork Office
Soaring Eagles Education
Youth Empowerment
Sign Up
Useful Forms
Flyers
Contact Us
Signup
Educational Pathways
Now includes
• After School Program • Tutoring • Youth Empowerment •
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Welcome to Educational Pathways
for the
2022-2023 School Year
The application for Educational Pathways is quite long.
There is 9 sections to fill information about you and your youth(s).
We have shorten the form so you don't have to repeat your information that is on the paper version. FYI the paper version is 14 pages long.
If you prefer a paper version we can get you one. Just call the Family Wellness Department at (559) 877-7277 and anyone will be able to help get you a paper application.
Click on the "Next" button to start the application process.
Next
Participant Service Location
Choose your service area location:
*
Fresno County (NFR Tribal Citizens Only)
Madera County
Mariposa County
Merced County
Monterey County
San Benito County
San Luis Obispo County
Required
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:
*
Required
(If no number use all zero)
Mobile Phone Number
*
Required
(If no number use all zero)
Day Phone Number:
*
Required
(If no number use all zero)
Date of Birth
*
MM
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YYYY
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2022
2021
2020
2019
2018
2017
2016
2015
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2011
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Place of Birth:
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chukchansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Degree or Highest Grade Attended
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(If not attending school use n/a or None)
Next
Adult Household Information
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Family Type
*
1-Parent
2-Parent
Relative Home
Other
Required
TANF Cash Aid
*
YES
NO
Required
Total Number of Dependants under 18 yrs old
*
Required
Total Number In Household
*
Required
Previous
Next
Emergency Contact Information
Emergency Contact One
Full Name
*
Required
Phone Number
*
Required
(If no number use all zero)
Cell Phone Number
*
Required
(If no number use all zero)
Emergency Contact Two
Name
Phone Number
Cell Phone Number
Insurance Information
Insurance Carrier
*
Required
Policy Number
*
Required
Family Physician Name
*
Required
Physician Phone Number
*
Required
(If no number use all zero)
Previous
Next
At Risk Indicators
Required
Must Include Two Yes
Please Check All That Apply
Living in high crime rate area
*
YES
NO
Required
Member of low-income family
*
YES
NO
Required
Absent parent (single parent children)
*
YES
NO
Required
Low academic skills (not low intelligence)
*
YES
NO
Required
Parents are not high school graduates
*
YES
NO
Required
Homelessness / housing
*
YES
NO
Required
Living with caretaker / relative
*
YES
NO
Required
Substance abuse issues
*
YES
NO
Required
Have negative self-preceptions; low self-esteem
*
YES
NO
Required
Pregnant / parenting teen
*
YES
NO
Required
Living on or near Rancheria lands
*
YES
NO
Required
Domestic violence
*
YES
NO
Required
Previous Involvement in Juvenile Justice System
*
YES
NO
Required
Living in unstable school district
*
YES
NO
Required
Any Other Risk Indicators not listed
YES
Enter Other At Risk Indicators
*
Required
Previous
Next
Participants Information
You are already included.
Just enter other Participants/Household members)
Maximum Number of Participants is 7
Participant One Information
Legal First and Last Name
*
Required
Relationship to Participant One
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
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YYYY
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2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2003
2002
2001
2000
1999
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1997
1996
1995
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1993
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1991
1990
1989
1988
1987
1986
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1984
1983
1982
1981
1980
1979
1978
1977
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1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
Allergic Reactions
*
Yes
No
Required
Type of Allergies
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
Required
Add Participant Two?
Yes
Participant Two Information
Legal First and Last Name
*
Required
Relationship to Participant Two
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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18
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22
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25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Participants Two Gender
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
Add Participant Three?
Yes
Participant Three Information
Legal First and Last Name
*
Required
Relationship to Participant Three
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
Add Participant Four?
Yes
Participant Four Information
Legal First and Last Name
*
Required
Relationship to Participant Four
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
Add Participant Five?
Yes
Participant Five Information
Legal First and Last Name
*
Required
Relationship to Participant Five
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
Add Participant Six?
Yes
Participant Six Information
Legal First and Last Name
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Relationship to Participant Six
*
Required
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
Add Participant Seven?
Yes
Participant Seven Information
Legal First and Last Name
*
Required
Relationship to Participant Seven
*
Required
Tribal Affiliation
*
Required
example: (North Fork Rancheria Mono, Chucksansi, Big Sandy, Tachi, None, n/a) [you can add more then tribe if you wish]
Marital Status
*
Single
Married
ReMarried
Separated
Divorced
Widowed
Required
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
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Required
Gender
*
Male
Female
Other
Required
Grade going into this school year
*
Infant
Head Start
T-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Certificate
Diploma
Some College
Associate
Bachelor
Master
Doctorate
Required
Name of School Attending
*
Required
(if not attending use n/a)
Allergic Reactions
*
Yes
No
Required
Type(s) of Allergies
*
Required
Asthma
*
Yes
No
Required
Type(s) Asthma Medication Taken
*
Required
Diabetes
*
Yes
No
Required
Type(s) of Diabetes Treatment
*
Required
Medication Taken Regularly
*
Yes
No
Required
List Types of Medication, Dosage, and Schedule
*
Required
Other Medical Conditions
*
Yes
No
Required
List Other Medical Conditions
*
Required
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Transportation and Program Release
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.
Are you Requesting Transportation
*
Yes
No
Required
Is the Drop off location the same as your address you filled at the start of the form
*
Yes
No
Required
Address
*
Required
City
*
Required
Zip
*
Required
In case the participant parent/guardian cannot be reached, the participant will be released to the following adults.
Adult One
Adult One Full Name
(optional)
Adult One Day Time Phone
(optional)
Adult One Cell Phone
(optional)
Adult One Relationship to Participant
(optional)
Adult Two
Adult Two Full Name
(optional)
Adult Two Day Time Phone
(optional)
Adult Two Cell Phone
(optional)
Adult Two Relationship to Participant
(optional)
Adult Three
Adult Three Full Name
(optional)
Adult Three Day Time Phone
(optional)
Adult Three Cell Phone
(optional)
Adult Three Relationship to Participant
(optional)
Adult Four
Adult Four Full Name
(optional)
Adult Four Day Time Phone
(optional)
Adult Four Cell Phone
(optional)
Adult Four Relationship to Participant
(optional)
Adult Five Full Name
(optional)
Adult Five Day Time Phone
(optional)
Adult Five Cell Phone
(optional)
Adult Five Relationship to Participant
(optional)
Adult Six Full Name
(optional)
Adult Six Day Time Phone
(optional)
Adult Six Cell Phone
(optional)
Adult Six Relationship to Participant
(optional)
Adult Seven Full Name
(optional)
Adult Seven Day Time Phone
(optional)
Adult Seven Cell Phone
(optional)
Adult Seven Relationship to Participant
(optional)
Adult Eight Full Name
(optional)
Adult Eight Day Time Phone
(optional)
Adult Eight Cell Phone
(optional)
Adult Eight Relationship to Participant
(optional)
Adult Nine Full Name
(optional)
Adult Nine Day Time Phone
(optional)
Adult Nine Cell Phone
(optional)
Adult Nine Relationship to Participant
(optional)
Adult Ten Full Name
(optional)
Adult Ten Day Time Phone
(optional)
Adult Ten Cell Phone
(optional)
Adult Ten Relationship to Participant
(optional)
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North Fork Rancheria Tribal TANF Family Wellness Youth Center Facility Rules & Computer Use Agreement
North Fork Rancheria Tribal TANF Family Wellness Youth Center Facility Rules & Computer Use Agreement 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.
• 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.
• 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.
Type your Signature
*
Required
Informed Consent and Disclosures and Rules
I understand that the services and rules provided at the Family Wellness Youth Center may include the following:
• No cell phone usage unless in the case of an emergency.
• No Verbal or physical abuse towards any persons or staff attending Family Wellness Youth Center events is allowed.
• No swearing is permitted.
• Please sign in and for all family members in attendance.
• 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
• Arts, Crafts, Recreational Activities
• Gang Prevention
• STD & HIV Education/Prevention
• Computer & Internet Access
• Holiday Events
I authorize the Family Wellness Youth Center staff, volunteers, and consultants to assist, teach, inform, and involve participant/child in the above services.
*
Type your Initial
My participant/child can participate in all of the services mentioned above except for:
*
Type your Initial
Type what program exemptions services mentioned above
I give permission to the Family Wellness Youth Center to transport my child for activities as verbally requested by a parent/legal guardian.
*
Type your Initial
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.
*
Type your Initial
I understand I will not be charged for Family Wellness Youth Center services.
*
Type your Initial
Type your Signature
*
Type your Initial
Release and Waiver of Liability Assumption of Risk and Indemnity Agreement
(Read Carefully Before Signing)
IN CONSIDERATION of being allowed to participate in activities sponsored by the Family Wellness Youth Center (“FWYC”), a governmental program 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.
Initial Here
*
Type your Initial
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.
Initial Here
*
Type your Initial
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.
Initial Here
*
Type your Initial
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.
Initial Here
*
Type your Initial
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.
Type in your Signature
*
Type your Initial
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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 Information
We use digital communications to contact you for any program updates or events
E-Mail Address
*
REQURIED FOR CONTACT, ZOOM OR ANY TYPES OF 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 or 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.
Submit