NACA L.I.F.E. Community Beading Circle
All skill levels and ages welcome!
Join us to start a new beading project or bring a project you might have started with us at a previous event.
All supplies will be provided.

When: Every Wednesday in April (April 5, 12, 19, 26) from 5 to 6 pm
Where: NACA Wellness Center

Contact Morgan for any further questions (928)773-1245 ext. 234 or email at mfarley@nacainc.org
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Full Name (First and Last) *
Email *
Date of Birth *
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Ethnicity *
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What is your tribal affiliation? (if applicable)
Gender *
Phone Number *
Address, City, State, ZIP code *
Emergency Contact (Name, Relationship, Phone #) *
Are you a *
Required
Cultural and Social Connectedness *
Strongly disagree
Disagree
Agree
Strongly Agree
I feel proud to be Native.
I have a strong sense of belonging to my community/nation/tribe.
I feel a strong attachment towards my community/nation/tribe.
I feel a strong connection to my ancestors.
It is important to me that I learn, know, or teach my Native American/Indigenous or tribal language(s).
I plan on trying to find out more about my Native/tribal culture, such as its history, traditions, and customs.
I feel close to the people in my family.
I am able to connect with other people in my community.
I feel understood by the people I know.
How often do you engage in each of the following traditional activities? *
Weekly
Monthly
Occasionally
Never
Plant/medicine gathering
Fishing/hunting
Food gathering (growing and harvesting crops, pinon picking, berry picking, etc.)
Native dance or drumming
Native crafts (beading, sewing, silversmithing, weaving, etc.)
Other traditional activities
How would you rate your confidence level in beading? *
Not confident
Very confident
Have you or are you participating in other tribal activities or another program that promotes cultural teachings for health and wellness? *
If yes, please describe
Would you like to be contacted regarding future NACA Health Promotion events? *
How did you hear about our event?
I hereby release and agree to hold NACA Wellness Center harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of NACA Wellness Center, or that may otherwise arise in any way in connection with any services received from NACA Wellness Center. I understand that this release discharges NACA Wellness Center from any liability or claim that I, my heirs, or any personal representatives may have against NACA Wellness Center with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from NACA Wellness Center. This liability waiver and release extends to NACA Wellness Center with all owners, partners, and employees. 
IF YOU AGREE TO THE ABOVE STATEMENT,  SIGN YOUR NAME BELOW:
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DISCLAIMER NOTICE: I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that NACA Wellness Center has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that NACA Wellness Center cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, NACA Wellness Center staff, and other NACA Wellness Center clients/participants and their families. I voluntarily seek services provided by NACA Wellness Center and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending this event. I attest that:
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The NACA Marketing Officer will be taking photographs at the event. These photos will only be used for NACA Marketing purposes. If you do not want to be included in any photographs, please let us know below. 
Do you give consent for NACA to use your likeness in photographic marketing material?

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