Spring Virtual GONA 2021

Virtual GONA for Youth Ages (5-24) and Families

Jotform program is HIPPA compliant. All information will be store securely.
Participant Registration

Please register each participant separately
GONA Dates:

June 7th 8th 9th & 10th on ZOOM! Time: 4:00pm-6:30pm each day

Important Information
- In order for Adults (25+) to participate, they should be participating as a family with their youth.
- ONLY BAY AREA PARTICIPANTS WILL RECEIVED A GONA BOX
- For questions email or call: Youth@nativehealth.org or (510) 434-5432
WHAT IS GONA?

GONA is a Native American Substance Abuse Prevention Curriculum created by Native People for Native People designed to strengthen communities and individuals through wellness. The central theme of the GONA is community healing from historical trauma as approached through the experiences of Native Americans.

GONA emphasizes inclusion and individual responsibility to promote healing in a safe environment. This retreat will lead you on a personal and community-driven journey.

GONA curriculum is a nationally recognized “best practice” by the Substance Abuse and Mental Health Services Administration. Native American Health Center staff and Youth Services department will be facilitating this event.

GONA will enable youth to learn self-reliance, ways to empower themselves and learn to live a healthy lifestyle in two worlds of culture and tradition walking in balance.

Participant Information
Please keep the Family name the same for each registered Participant. This will help keep your family in the same group.

Example: The Robinson Family
Family Name*
Participants Full Name:*
Date of Birth:

MonthDayYear
Date
Gender:*
Ethnicity :*
If Native American Tribal Affiliation:
Address needed for delivery purposes.
Street Address:*
APT #
City:*
State:*
Zip Code:*
T-Shirt/Hoodie Size (hoodies are adult sizes)*
By adding your email, you are agreeing to received emails from NAHC Youth Services Program. We will also be sending the Zoom ID # to this email.
Youth Email:
example@example.com
Parent/Guardian Information
Parent/Guardian:*
Relationship to youth:*
Home Phone:
Work:
Cell:*
By adding your email, you are agreeing to received emails from NAHC Youth Services Program. We will also be sending the Zoom ID # to this email
Parent Email:

Consent Information
I understand and acknowledge that by checking the box below, I am agreeing to all of the statements in this document.

My child/youth has permission to be participate in the Youth Gathering of Native AmericansI give my permission for the Photographs and/or videos being recorded on ZOOM of my child/youth/family to be used by Native American Health Center for promotional, documentation, and/or grant funding purposes.I give my permission for my child/youth to take part in surveys and/or evaluations to assist in the process of grant proposals, fundraising, program information/documentation and promotional use.I understand that all staff are mandated reporters and that all information shared during Youth GONA will remain confidential and will not be shared with others without my consent. I also understand that there are conditions under which this confidentiality must be broken and information about my child must be shared with the appropriate individuals. These conditions are as follows: there is a suspicion of child abuse/neglect; participant is in danger of hurting himself/herself; participant is in danger of hurting another.I give my permission for my child/youth to benefit from additional support and referral services which are provided by Youth Services and Community Wellness Department staff. Services are voluntarily, but if the need arises you are giving prior consent for your child to participate in prevention and/or early intervention services. These services are not mental health treatment services. Services are funded through the Alameda County Behavioral Health Care Services (ACBHCS) Network. Youth participant’s information is considered confidential and is guided by regulations regarding the use and disclosure of confidential health information (HIPPA Your identifying information is shared with Alameda County Behavioral Health Care system .Youth have the right to choose to participate or not participate in these services and have the right to stop services at any time
Parent and/or Legal Guardian having legal custody of youth participant:
Signature:

Clear
By my signature I give my consent and agreement to the above statement
Today's Date:

MonthDayYear
Date

OFCY CONSENT FORM

(For participants age 17 and under)
Jotform program is HIPPA compliant. All information will be store securely. You may preview the form at the end before submitting
Dear Parent/Guardian,

All personal information will be kept in a secure environment.

By signing The Release of Information-Evaluation and Photo/Video Permission form, you are giving us permission to enter the requested information into the OFCY (Oakland Fund for Children and Youth) database (Cityspan). Also if checked and signed it gives permission for your child/youth to be videotaped and/or photographed, this is usually during activities and is used for promotional purposes. OFCY is one of our major funders giving us the ability to provide the wonderful programming we offer to your child/youth. Please be reassured all of your child/youth(s) information will be held in our office in a locked space and always treated confidentially. The only information we share with our funder about your child/youth will be the following.

Child/Youth: Name
Date of Birth
Ethnicity
Gender
Zip Code

Please read OFCY Consent form below.
If you have any questions or concerns please let us know

Thank you

NAHC Youth Services Program
510-603-2600
youth@nativehealth.org

EVALUATION OF PROGRAMS
The Oakland Fund for Children and Youth (OFCY) provides grants to many programs serving youth and their families in Oakland. OFCY programs serve thousands of youth ages 0 to 21 and their parents/ caregivers and include everything from parent education programs to youth leadership and career development programs.

All programs funded by OFCY are required to participate in an independent evaluation. Part of this requirement is to report on who is served and how much and what types of services participants received. Grantees enter this service information through a secure, password-protected online grant management system. However, no single participant will ever be identified in any evaluation. Data is only used in the aggregate to report program and fund performance.

As part of the evaluation, children and youth may be asked to complete surveys and participate in focus groups. The survey, intended for children in third grade and above, asks what children and youth do in their program, how much they like what they do, and demographic information. Again, no specific child or youth will be identified in evaluation reports. Survey and focus group findings will only be summarized.

I give permission for my data to be used in the evaluation of OFCY funded programs.
Your Child’s Name
Parents/Guardians Name
Parents/Guardians Signature

Clear
Today's Date

MonthDayYear
Date
PHOTO/VIDEO RELEASE

Optional
During your child’s participation in the OFCY-funded program, they may participate in an activity that is being photographed or video recorded. These photographas/video recordings may be used with your permission for OFCY promotional purposes. The evaluation and photos/videos help tell the story of the impact of OFCY funded programs.

This helps to inform the Oakland community about the positive benefits resulting from the public investment of OFCY funds to support programs serving children and youth presently and in the future. I give permission for OFCY to use photographs or videos of my child.

I give permission for OFCY to use photographs or video of my child
Parents/Guardians Signature

Clear
Today's Date

MonthDayYear
Date

Should be Empty:

Virtual GONA for Youth Ages (5-24) and Families

Participant Registration

Participant Information

Parent/Guardian Information

Consent Information

OFCY CONSENT FORM

EVALUATION OF PROGRAMS

PHOTO/VIDEO RELEASE