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G.U.I.D.E. Youth Prevention Program Registration Form


PROGRAM DESCRIPTION

Tewa Roots Society's Basecamp After School Program is a prevention and mental health program. We offer youth the opportunity to collaborate on youth-led initiatives, have access to mental health resources, work on self-esteem building, learn communication skills, practice self-care, learn how to create safe and equitable space, and participate in cultural programming like beading, traditional cooking, regalia making and a variety of other activities that incorporate Tewa language and traditions.

Our Basecamp After School Program facilitators will offer outdoor adventure and youth empowerment programming, Youth Council involvement, therapeutic group work, space for processing emotions and thoughts that arise during activities, and peer support. We offer many activities including a large assortment of experiential games and activities facilitated from a cultural lens created by clinical and mental health professionals for therapeutic purposes. We value our connection to land, water, and our plant and animal relatives, and we regularly demonstrate how these reciprocal relationships can nurture therapeutic effects. These therapeutic effects are also imperative to our suicide and substance use prevention programming because they help empower and build the resilience of our youth and teach them new skills to navigate the complex challenges that exist in our communities.

Please read through and fill out the following form thoroughly. If there is any missing information, we will contact you and ask you to complete your submission.


BASECAMP REGISTRATION FORM

This registration form must be signed by each adult (18 years of age or older) participant in a Tewa Roots Society event, or by the parent or legal guardian of a minor participant. “Participant” as used in this agreement refers to persons participating in an event, observers, chaperones, and others on the premises of Nambé Pueblo or any other activity sites. Minor participants must sign inside the box on the last page to acknowledge their understanding of the activities and risks, and rules and responsibilities.


ATTENDANCE POLICY NOTICE

Although daily attendance is not a requirement of Basecamp registration, attendance will be tracked via our sign-in process. That said, consistent attendance and participation, or lack thereof, may affect your youth's ability to participate in special trips/opportunities that Tewa Roots Society Basecamp Program may offer in the future (e.g. Adventure Programming and Youth Council activities). If youth will be absent, we request that the youth or guardian notify a member of TRS Youth Program staff as soon as possible.



First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Third Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
Parent or Guardian's Email Address
Email*
Confirm Email*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Confidential Medical History
Medical Insurance Provider *
Policy #
Physicians Name
Physician's Phone Number
Does your youth have any known heart problems?*
No
Yes
If yes, please explain:
Does your youth have any physical limitations, seizures, hospitalizations, or recent injuries? *
No
Yes
If yes, please explain:
Does your youth have Asthma? Is it mild, moderate, or severe? Do you carry an inhaler?*
No
Yes
If yes, please explain:
Is your youth CURRENTLY taking any medication? If so, which medication and are there any side effects?*
No
Yes
If yes, please explain:
Does your youth have any ALLERGIES to medicines, foods, materials, or insect bites? (Please specify) *
No
Yes
If yes, please explain:
Does your youth carry epinephrine (an epi pen)? *
No
Yes
Is your youth pregnant? *
No
Yes
Is your youth diabetic?*
No
Yes
If yes, please explain:
Does your youth carry a blood glucose monitor? *
No
Yes
Does your youth have mental health concerns and/or diagnoses (i.e. depression, suicidal ideation, anxiety, ADD, ADHD, etc.)? *
No
Yes
If yes, please explain:
Does your youth have any dietary restrictions (i.e. vegetarian, vegan, gluten-free, lactose intolerant)? *
No
Yes
If yes, please explain:
Additional comments regarding pertinent medical information:
AUTHORIZATION FOR MEDICAL CARE “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 permit the TRS staff to render first aid and to seek emergency medical and rescue services for myself or my child.” *
No
Yes
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*
Select Gender
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information

YOUTH PARTICIPANT - BASIC INFORMATION

Age: *
Grade: *
Pronouns: *
Height: *
Weight: *
School: *
Tribal Affiliation: *
Ethnicity: *
Does TRS Staff have permission to contact the youth participant via their provided email and phone number above?*
Yes
No

PICK-UP AUTHORIZATION LIST

Please list the name, phone number, address, and relationship of each individual you are authorizing to pick up your participant. Should you neglect to provide all the necessary information, a Tewa Roots Society Team Member will contact you and ask you to update your form. No one else will be allowed to pick up your minor unless you update this form. Please notify the Program Director if you would like to make any changes.

First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:
First Name Last Name:
Cell Number:
Relation:
Physical Address:

TRANSPORTATION AGREEMENT

While Tewa Roots Society does not yet offer full transportation services for youth living outside of Nambé Pueblo, we will be able to drop youth off at a pick-up point in Pojoaque to help parents in the evenings. The pick-up point is the Cities of Gold Bowling Alley parking lot between 5:45 PM-6:00 PM. ONLY authorized adults will be allowed to pick youth up at the pick-up point. Youth participants who live in Nambé are eligible for transportation directly to their homes.

Youth living in Nambé will only be dropped off at their home address(es) listed on this form. If youth need to be dropped off at another location within Nambé, parents/guardians must first contact TRS staff to provide authorization.

Will your minor need transportation to the parent pick-up point in Pojoaque?*
No
Yes
Will your minor need transportation home (within the Nambé area)?*
No
Yes

"I permit for my minor to be transported by Tewa Roots Society staff using vehicles issued to them by Nambe Pueblo. I shall not hold Nambé Pueblo or its employees providing services and activities liable for any accidents, injuries, or loss of property that may occur during any activities, nor during travel to and from activities. It is my responsibility as a guardian to provide all necessary medical information in case of injury or accident that may occur to ensure that my child may receive assistance immediately."

INDEPENDENT YOUTH AUTHORIZATION

(Only for participants 14 years and older)

We understand that giving your youth permission to walk home after leaving the Tewa Roots Society Basecamp may be the best option for you, so please choose the one statement you agree with below to authorize. (Please consider the weather and time of sunset on any given day that your youth will be walking home. Tewa Roots Society staff will not be obliged to drive youth home due to bad weather conditions.)

Please understand that by submitting this wavier you are agreeing to the following statement:

"I understand that my youth is no longer under the supervision of Basecamp staff once they leave the facility for the day."

Please read each option carefully and provide your preference below:

OPTION 1: "My youth can leave Basecamp anytime before closing at 5:30PM."

OPTION 2: "My youth can leave Basecamp only after it closes at 5:30PM."

OPTION 3: "My youth cannot leave Basecamp on their own at any point."

“I choose Option .”*
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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