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TEWA ROOTS SOCIETY RELEASE OF LIABILITY

For and in consideration of the services of Tewa Roots Society I, the Parent or Guardian of a minor Participant (for myself and, to the maximum extent allowed by law, for the minor participant), acknowledge and agree as follows:  

THE PROGRAM AND ITS ACTIVITIES 

Tewa Roots Society is a program under Nambe Pueblo’s Healthy Family Services, (a Federally Recognized Tribal Entity department), and is an experiential learning program.  Recently developed, it uses an action-oriented, experienced-based approach to personal learning, growth and reflection. Participants may be asked to become engaged in a series of mentally and physically challenging activities including cooperative games, trust building activities, problem-solving initiatives, adventure challenge courses, developing wilderness skills including overnight camping, cooking, whitewater rafting, rock climbing, backpacking, hiking, snowshoeing, recreational kayaking, snowboarding, whitewater kayaking, sustainable building, and transportation by vehicle to certain activity sites.  Some groups will include a licensed therapist for individual or group needs. During and following the activities, discussions or debriefings focus on identifying and understanding communication patterns, relationships, problem-solving techniques, and areas of competence. Tewa Roots Society’s strength-based approach affords opportunities for enrichment and increased resiliency for those who participate in its innovative and progressive community based, educational and therapeutic work. More information about Tewa Roots Society may be found on our Facebook page at @TewaRootsSociety or by calling us at (505) 455-5591.  

RISKS

Tewa Roots Society’s activities have physical and emotional risks. The well-being of participants is always a priority of Tewa Roots Society’s facilitators, and participants are given a choice regarding their level of participation. The nature of the risks varies significantly based on the individual participant and the activity. These risks may be physical, including running, jumping, stretching, lifting, and other physical exertion which may result in pulled or strained muscles, tripping, broken bones, or other serious injuries including, in extraordinary circumstances, even death.  Other risks may be emotional, including fear of heights, close personal contact with and dependency on others, self-disclosure, trust, giving/receiving support, and expressing feelings of anger, fear, and/or affection. Participants may act carelessly, and cause harm to themselves and others. Tewa Roots Society’s employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might malfunction. These risks (Physical and emotional), are inherent in the activities, but without them the activity would lose its value and appeal and vigorous participation would be discouraged. Participant, or parent, consents to the Tewa Roots Society staff transporting participant to and from program sites, and acknowledges that such activity involves the risks of vehicle travel. Other risks, inherent and otherwise, will be encountered.    

I understand that participants must be free of known conditions – medical, physical and mental - that may cause them to be a danger to themselves or others.  If in doubt, participant must seek medical advice before participation in the Tewa Roots Society program to determine his or her suitability for the activities. Participant or parent agrees to assume the risk of any medical or physical condition the participant may have.  Participant or parent also agrees to inform the facilitators of any such conditions and of any situation or conditions related to the activity itself that may be a danger to participant or others. These situations may include: a) broken equipment, b) illness of tiredness that may affect a participant’s performance or judgment, and c) having difficulty performing a skill. Participant or parent also agree to abide by rules and responsibilities described by the staff and understand that failure to comply with these may result in the participant being removed from the activity or activity site.     

ASSUMPTION OF RISKS  

I agree to assume and accept any and all risks of Tewa Roots Society’s activities and moving about the Pueblo and other activity sites, inherent and not, and whether or not described above.  If the participant is a minor, I, the parent, have described the activities and risks, rules and responsibilities to the child who understands them and wishes to participate nevertheless.  

RELEASE AND INDEMNITY 

I, an adult participant, or parent of a minor participant (Parent agreeing for  himself or herself and, to the extent allowed by law, for the minor Participant) hereby agree to release and not to sue, and to indemnify (including to defend against and pay claims and costs including attorney’s fees and insurance deductibles)  Tewa Roots Society, its director, governing body, staff and contractors (“Released Parties”) from all claims of injury or loss to me or to the minor child, in any way arising out of my, or the minor child’s, participation in an activity of Tewa Roots Society, or being on the premises of the Pueblo or another activity site, whether caused by negligence, breach of contract or otherwise, and including bodily injury, death, property damage or other loss.   

LAWS AND VENUE

I agree that any dispute between a Released Party and a participant or parent will be governed by the substantive laws (not including laws which might apply the laws of another jurisdiction) of the Pueblo of Nambe. Any mediation or suit shall take place only in that Pueblo.

RELEASE OF LIABILITY

This agreement, which consists of this and the preceding one page, will apply to my, or the child’s, participation in activities of Tewa Roots Society now and in the future until or unless a new agreement is signed pertaining to later visits. I agree that if any portion of this agreement is found by a court of competent jurisdiction to be void or unenforceable, the remaining document shall remain in full force and effect. I, a parent or guardian of a minor participant, have carefully read this agreement and understand its contents, and I sign it of my own free will. I am aware that this agreement includes a release of liability, and is a binding contract between the  Pueblo of Nambe and myself, and it likewise shall be binding, if applicable, on my minor child who is a participant, and on my, and the minor child’s, heirs, executors and administrators.


I, a parent or guardian of a minor participant, have carefully read this agreement and understand its contents, and I sign it of my own free will. 

I Agree
 

Parent/Guardian Signature

 September 15, 2026

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Parent or Guardian's Email Address
Email*
Confirm Email*
Guardian Information
First and Last Name *
Relationship to Participant *
Phone Number *
Email *
What is the best way to contact you?*
Call
Text
Email

Additional Guardian Info

First and Last Name
Relationship to Participant
Phone Number
Email
What is the best way to contact you?*
Call
Text
Email
If there is more than one parent or guardian, who will be the primary point of communication for TRS staff to contact first?
First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Email
It is OK for TRS staff to text the participant directly about program matters
It is OK for TRS staff to call the participant directly about program matters
It is OK for TRS staff to email the participant directly about program matters
Any dietary restrictions or food intolerances? *
Gender *
Pronouns
Ethnicity
Mexican
Cuban
Puerto Rican
Hispanic (other specific)
Hispanic (origin not specified)
Not Hispanic or Latino
Unknown
Race
African American
Alaskan Native
Native American
Native Hawaiian/Other Pacific Islander
Asian
Two or more races
White
Unknown
Tribal Affiliation *
Tewa Name (if applicable)
First Participant's Signature*
Medical Questionnaire
Medical Insurance Carrier *
Height *
Weight *
Gender assigned at birth *
Does the participant take any medications?*
No
Yes
Please note medication name, dose, frequency, and any side effects.
Does the participant have any allergies?*
No
Yes
Please note allergen, reaction, and if the participant carries an epi-pen.
Does the participant have asthma?*
No
Yes
Is it mild/moderate/severe? Does the participant carry an inhaler?
Physical limitations or injuries that may impact mobility*
No
Yes
Please note type of mobility impairments/pain and what triggers pain, as well as any accommodations the participant may need in order to participate.
Diabetes*
No
Yes
Please share any management strategies that our staff can prepare for and help with.
Mental health diagnoses or challenges*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of self-harm, suicidal, or violent ideation or behavior.
Medical conditions (including heart, respiratory, neurological, etc.)*
No
Yes
Please explain any medical conditions the participant lives with.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization and outcome.
To the best of my knowledge, I or my child is physically and mentally able to participate in the Tewa Roots Society program. I have (or have assisted my child) in completing the Medical History section with health information that is accurate, complete, and true to the best of my knowledge. Should I become incapacitated (or my child becomes ill or injured), I give permission for the TRS staff to render first aid and to seek emergency medical and rescue services for myself or my child. *
I agree
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Participant Rights and Responsibilities

PARTICIPANT RIGHTS

1. I have the right to receive competent and appropriate program services.

2. I have the right to information on the nature of care, procedures, and treatment that will be provided.  

3. I have the right to receive answers to questions or concerns related to services provided. 

4. I have the right to participate in the development of individual treatment plans and any subsequent recommendations. 

5. I have the right to the knowledge of the credentials and experience of the staff responsible for my care.

6. I have the right to receive respectful treatment by staff. 

7. I have the right to receive services that respect my dignity, and protect my health and safety. 

8. I have the right to receive services regardless of gender, religion, race, creed, nationality, or sexual preference. 

9. I have the right to be reasonably informed of the benefits and risks of all program activities. 

10. I have the right to decline to engage in activities that cause me to feel at risk or unsafe, either physically or emotionally. 

11. I have the right to be free from any physical or verbal abuse. 

12. I have the right to remain free of physical restraints or time-out procedures unless such measures are required for providing effective treatment, or protecting the safety of self or others. 

13. I have the right to confidentiality, which means that any personal information shared with Tewa Roots Society staff may not be disclosed to anyone who is not directly associated with Tewa Roots Society, without signed consent by the participant, or the participant’s parent/guardian (if under 18 years of age). Exceptions to confidentiality are: a) Court referrals b). Threats of harm to self or others c) Disclosure of alleged abuse or neglect d) Signed Information Release to a specific individual or agency. 

14. I have the right to request copies of records and reports about me (unless otherwise provided by law). 

15. I have the right to initiate a complaint or grievance procedure and to receive appropriate information concerning this procedure upon request. This includes the right contact funders with grievances such as the New Mexico Crime Victim Reparation Committee. 


I have read and understand the rights the participant is entitled to.

Participant Responsibilities Statement 

1. Attend program activities. If there is some reason I cannot attend a program, I will notify staff in advance. 

2. Participate in all activities to whatever degree I am able. 

3. Abide by any special rules (situational) developed to ensure the health, safety, or and welfare of participants and staff. 

4. Read the above policies concerning my rights.

 5. Do not carry knives, blades, firearms, or any weapon while participating in program activities. 

6. Refrain from the use of illegal drugs and from the use of alcohol while involved with Tewa Roots Society. 

7. Refrain from sexual remarks or contact with other participants.

8. Stay within verbal contact distance unless staff has been succinctly notified of my intent to exceed this distance. 

9. Replace or pay for any property damage or loss due my negligence or acting out behavior. (Normal wear and tear is exempted from this agreement.)  

I have read and understand that I (or my child) has these specific rights and responsibilities outlined in the Participant Rights and Responsibilities section. I also understand that I as a participant (or as a Parent/Guardian on behalf of a minor participant) have the right to file a grievance if I desire to do so. If I desire to file a grievance, a form for filing the grievance will be sent to me within five working days of its request, along with an outline of the procedures for filing the grievance. The grievance will be reviewed as soon as it is received by the Tewa Roots Society, and a written response will ensue within five working days. *
I agree
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Email
It is OK for TRS staff to text the participant directly about program matters
It is OK for TRS staff to call the participant directly about program matters
It is OK for TRS staff to email the participant directly about program matters
Any dietary restrictions or food intolerances? *
Gender *
Pronouns
Ethnicity
Mexican
Cuban
Puerto Rican
Hispanic (other specific)
Hispanic (origin not specified)
Not Hispanic or Latino
Unknown
Race
African American
Alaskan Native
Native American
Native Hawaiian/Other Pacific Islander
Asian
Two or more races
White
Unknown
Tribal Affiliation *
Tewa Name (if applicable)
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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