NUI Partnership For Success Program Enrollment Form 2023-2024
Email *
Full Name of Youth Participant
Age *
Gender *
PRIMARY GUARDIAN
Full Name *
Relationship *
Full Address *
Contact Information (Phone & Email) *
EMERGENCY CONTACT
Full Name *
Relationship *
Contact Information (Phone & Email) *
YOUTH INFORMATION
For School Year 2022-23
Current School *
Current Grade Level *
Does Your Child Have Any Allergies We Should Know About *
Is Your Child Of Hispanic Ethnicity *
Race *
If Identified As American Indian/Alaskan Native Are You Urban *
Tribe
Enrollment #
Indian Quantum/Blood Quantum
Program Interest *
Untitled Title
Partnership for Success is a federal grant supported program through the Substance Abuse and Mental Health Service Administration (SAMHSA) I am aware and accept that my child will attend substance use prevention, suicide awareness and prevention, healthy living, life skills and mental health and wellness focused curriculum based programs.
PARENT / GUARDIAN INFORMATION
Full Name *
Date Of Birth *
MM
/
DD
/
YYYY
Sex *
Marital Status *
Spouse Name
Spouse Date Of Birth
MM
/
DD
/
YYYY
Spouses Sex
Total # In Household *
Total Household Income *
Housing Status *
Race *
Are You An Enrolled Member Or Descendants Of A Federally Recognized Tribe... If So What's Your Tribe Of Membership *
Do You Live On A Reservation... If So Which One *
Are You The Spouse Of A Veteran.. If So Which One *
Are You Currently Employed *
Is Your Spouse Currently Employed
What Is The Highest Level Of Completed Education For You / Spouse *
Would You Like To Be Connected With Workforce Development Services *
Which Ones *

Nevada Urban Indians also provides clinical services, please answer the following to help us identify any need for referrals or resources to other NUI provided services.

Do You Or Anyone In Your Family... 

Have concerns about underage members of the family having access to alcohol or other substances in the home

Have concerns about underage members of the family having access to alcohol or other substances through peers or family members

 *

Have concerns with youth family members because they are already actively using drugs or alcohol

 *

Have a history of alcohol or substance abuse

 *

Have sought counseling for substance abuse

 *

Are in need of alcohol or substance abuse resources

 *

Have a youth family member that has unmet mental health and wellness needs

 *

Have a youth who needs mental health and wellness resources

 *

Have gone to therapy or family counseling

 *

Have a history of or experienced domestic or family violence

 *

Have experience emotional abuse

 *

Have experience emotional abuse

 *

Would like resources on mental health resources

 *

Have diabetes

 *

Have a family history of diabetes

 *
Untitled Title
Thank you for your interest in Partnership for Success, we serve youth ages 9-20 and required re – enrollment annually. You will be notified when your re-enrollment period is coming up, if you have any questions or concerns regarding the program contact PFS Program Coordinator.
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