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Tewa Roots Society Basecamp Programs Registration Form - GUIDE Youth Program


PROGRAM DESCRIPTION

Tewa Roots Society's Basecamp GUIDE 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 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.



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

 August 24, 2026

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

Additional Guardian Information (if applicable)

First and Last Name
Pronouns
Relationship to Participant
Phone Number
Email
What is the best way to contact you?
Call
Text
Email
First and Last Name
Pronouns
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

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
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 participant rights.

Participant Responsibilities Statement 

Parents/guardians should read and review these responsibilities alongside the participant to ensure understanding and agreement prior to program attendance.

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*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information

YOUTH PARTICIPANT - BASIC INFORMATION

Tewa Name (if applicable)
Phone Number
Email
It is OK for TRS staff to TEXT the minor directly about program matters
It is OK for TRS staff to CALL the minor directly about program matters
It is OK for TRS staff to EMAIL the minor directly about program matters
It is NOT OK to contact the minor directly about program matters or otherwise
Does the participant have any dietary restrictions, food intolerances, or other eating habits we should be aware of? *
Gender *
Pronouns:
Age: *
Grade: *
School: *
Tribal Affiliation:
Race/Ethnicity:

CONFIDENTIAL MEDICAL QUESTIONNAIRE

Medical Insurance Provider *
Policy Number
Physician's Name
Physician's Phone Number
Does the youth 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. *please send youth to program with their epi-pen if prescribed*
Does the participant have asthma?*
No
Yes
Is it mild, moderate, or severe? Is the participant prescribed an inhaler? How often do they use it? *please send youth to program with their inhaler if prescribed*
Does the participant have any physical limitations or injuries that may impact their mobility or participation?*
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.
Does the participant have diabetes?*
No
Yes
Does the participant have a blood glucose monitor? Please share any management strategies that our staff can prepare for and help with. *please send youth to program with their monitor if prescribed*
Does the participant have any mental or behavioral health diagnoses or challenges?*
No
Yes
Please disclose any medically necessary information regarding mental health, specifically if the participant has a recent history of substance abuse, self-harm, suicidal, or violent ideation or behavior.
Does the participant have any medical conditions? (including heart, respiratory, liver, neurological, etc.)*
No
Yes
Please indicate condition, past and present treatments, and any accommodations the participant may need to participate.
Any recent surgeries, hospitalizations, or injuries?*
No
Yes
Please share reason for hospitalization, outcome, and any continuing health needs due to hospitalization.
Is the participant pregnant or have they had a pregnancy in the past six months?*
No
Yes
Additional comments regarding pertinent medical information:

AUTHORIZATION FOR MEDICAL CARE

All TRS basecamp staff have at least a CPR/First Aid certification, and will respond to emergency health or medical situations if the parent or guardian gives prior consent. Please agree below if you consent to the following:

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 consent
I do not consent
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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