Navajo NARCH Service-Learning Spring 2021 Experience
 This is the application for the Navajo NARCH Service-Learning Spring 2021Experience for high school students. Application is due Friday February 26, 2021.

This google form consists of the following documents-
1. Application
2. Parent/Guardian Acknowledgment form (Parent initial required)
3. Native Connections Photo/Video/Audio Permission Form (Parent initial required)
4. Navajo Dept. of Health Navajo Epidemiology Consent Form (Parent and participant initial required)

Contact information:
Amber-Rose Waters, Project Coordinator
Email: ardbegay@dinecollege.edu  OR  isep@dinecollege.edu 
Phone: (505) 421-8817

Heather Dreifuss, Director
Email: hdreifuss@dinecollege.edu 
Phone: (503) 502-0776

Mailing address:
Linda Garcia
Dine College
P.O. Box 580
Shiprock, NM 87420


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Full name: (last, first, M.I.) *
Address *
Phone Number *
Alternate Phone Number *
E-mail Address *
Birth Date *
MM
/
DD
/
YYYY
Parent/Guardian Name *
Parent/Guardian Phone Number *
Person to contact in case of emergency and relationship *
Emergency Contact Phone Number *
Education *
Cumulative GPA *
Name of School Attending and Address *
School Phone Number *
Have you attended any service-learning programs? *
If yes, please type the name of the program(s), location, dates attended, and contact person.
Do you plan on attending a university, college, vocational/occupational program after high school? *
If yes, where do you plan on attending?
What do you plan to major in?
If no, please explain:
Please select your top 3 health profession choices from the list below: *
Required
What do you want to get out of this service-learning experience? *
What time/day are you in school (in-person and online) hours? *
Will you or do you participate in extracurricular or after school activities? *
Do you have internet access at home? *
Do you have a smart device that is accessible to work online? (please check) *
Required
What device do you have? (for example: smart phone, tablet, iPad, PC or MAC laptop or desktop computer) *
Parent/Guardian Acknowledgment Form
Parents please initial below if you give permission to have your student participate in the Navajo NARCH High School Service-Learning Spring 2021 Experience.

Release of Liability:

My initial is my full consent for my son/daughter to participate in the Navajo NARCH High School Service-Learning Spring 2021 and related activities sponsored by Diné College and Northern Arizona University. I further release Diné College and Northern Arizona University and any of its affiliates for the Navajo NARCH High School Service- Learning Program from any liability of accidents or injuries that may result as a part of the program’s activities/events. Furthermore, should any disciplinary issues arise during the length of the program, I will take full responsibility for my child’s actions and understand that it is the right of the Navajo NARCH High School Service-Learning program to release my child from the program for any reason deemed necessary. (i.e., discipline, non-compliance with policies & procedures, failure to complete assigned tasks, and excessive tardiness/absenteeism.) I will support my child in all components and requirements of the Navajo NARCH High School Service-Learning Spring 2021. I will encourage their full participation in all activities, including those listed below:

• Attend full internship hours, February 2021 to May 2021 (approximately 2 hours a week)

Parent Full Name *
Parent Initial *
SAMHSA Native Connections Photo, Video, and Audio Permission Form


The Native Connections is a project of the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services (HHS), being implemented by Tribal Tech, LLC (contractor), Kauffman & Associates, Inc. (subcontractor), and Wopila Consulting, LLC (subcontractor).

The Native Connections grant program supports grantees in:
-- Reducing suicidal behavior and substance use among Native youth up to age 24;
--Easing the impacts of substance use, mental illness, and trauma in tribal
communities; and
-- Supporting youth as they transition into adulthood.

The Native Connections is gathering photographs and audio/video footage of sponsored events and activities. Still and moving images will be used for project purposes only. Audiences may include, but are not limited to, AI/AN communities and villages, SAMHSA officials, federal agencies, and other local or regional stakeholders. Images of participants may be included in any of the following formats: PowerPoint slideshow presentations, reports, brochures, informational materials, website, e-newsletters, digital stories, and/or film presentations.
HHS/SAMHSA and/or its contractor will not record or reproduce any images of a communities sacred rituals or ceremonies Individuals and communities included in images will not be identified by name.

PARTICIPATION AND CONSENT: The Native Connections requests your permission to use photograghs, likenesses, artwork, profiles, and/or stories in all forms of media and all manners, including publications, web pages, videos, and other promotional material.

Please read the following statements and sign this form if you agree.

-I have read the above information and give my consent to HHS and its contractor to use my likeness and/or voice by photograph, film, video, or audio recordings and to use, reproduce, prepare derivative works, distribute copies to the public and broadcast publicly and display publicly the resulting work in any medium, and to permit others to do so for any government purpose.

-I release HHS from any liability resulting therefrom, as long as the work is used in a legitimate manner that is not intended to cause harm or embarrassment.

-I have read and understood this entire document, and I have willingly agreed to the above conditions.

When possible, the Native Connections will make an effort to notify you if photographs or footage of you is featured in any of the outreach materials To facilitate advance notice, please include your email address below.

AUTHORIZATION: I am over the age of 18. I have read the above statement and fully understand the contents of this photo, video, and audio permission form. In the case of a minor, I can attest that I have every right to initial this authorization form for my minor child in the above regard.


Parent Full Name *
Parent initial *
Parent email address *
Navajo Department of Health Navajo Epidemiology Center Native Connection Consent Form
Purpose:
Navajo Epidemiology Center's Native Connections Project will be conducting
a virtual workshop for Navajo (Diné) Youth. The purpose of this workshop is to allow our Diné Youth to embark in a process of self discovery and to reflect on growing up within the community. Each Youth participant will learn to create a 1 to 3 minute storytelling presentation on a topic relevant to Navajo Youth today and how they address adversity. Upon completion of the workshop, participants will learn digital median skills, tools and applications to communication and share their stories with their peers, family and community members.

Expected Participation: Your participation will participate in a virtual digital storytelling workshop. Each participant must be able to log on to the internet and participate in virtural workshop throughout the entire event.

Risk and Benefits: You may feel uncomfortable with some of the questions. You may opt- out of answering any question at any time without providing a reason. This workshop will focus on self-discovery, resilience building and strengths-based reflection.

Confidentiality: All information that is provided is confidential and the participant’s identity will be protected and will not be disclosed. The information we collect will be stored within the Navajo Epidemiology Center, Admin Building #2, Window Rock, Arizona, 86515, for up to two (2) years.

Participants Rights: Your participation is completely voluntary. You may refuse to participate or stop at any time, for any reason, without any penalty or discrimination. However, the Law requires us to report any child or dependent abuse. Interviewees that disclose a current violent situation or suicidal thoughts will be referred to the appropriate tribal agencies for services.

Contact Information:
Cheryl Willie, Community Involvement Specialist
Navajo Epidemiology Center
Navajo Department of Health P.O. Box 1390
Window Rock, AZ 86515 Telephone: (928) 245-4214

Ramona Antone Nez, Director
Navajo Epidemiology Center
Navajo Department of Health P.O. Box 1390
Window Rock, AZ 86515 Telephone: (928) 871-6239

By initialing this form I acknowledge that my child was provided information about the purpose, risk, benefits, and volunteer aspects, of participate in virtual digital storytelling workshop.I agree to allow my child to participate in Virtual Digital Storytelling Workshop.

Parent Full Name *
Parent Initial *
Participant Full Name *
Participant  Initial *
Emergency Contact Name and Number *
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