General Membership Form

General Membership Form

Northwest Indian Community Development Center
Boozhoo!/Aaniin!

Miigwech bi-izhaayan omaa

Northwest Indian Community Development Center!

Gikinwaa’amaading (Educating)

Wiidookoodaading (Connecting)

Aanjibizong (Transforming)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Current Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Tribal Affiliation
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Contact Relationship
Gender Identity
Race - Select all that apply

Native American / Alaskan NativeAsianAfrican AmericanHawaiian Native / Pacific IslanderHispanic / LatinoWhite
Are you a Veteran?

YesNo
Are you a US citizen

YesNo
Please check if you have the following

FelonyMisdemeanorArrest Record
Employment Status

Full-TimePart-TimeSelf-EmployedTemporary/SeasonalUnemployed
Housing Status

OwnerRentingHomelessStaying in a shelterStaying with relatives
Marital Status

SingleMarriedSeparatedDivorcedWidowed
What is your household size?
Do you currently have any children?   Yes    No
If yes, how many are under 18?
Are you the custodial parent of your children?   Yes     No
Are you currently expecting?   Yes   No
If yes, when is your expected due date?   Date
Do you receive public assistance?

YesNo
If yes, please list:
Please identify any challenges you are experiencing:

Handicapped/DisabledMental health concernsLearning disorder/disabilityLack of reliable/safe housingLack of transportationLack of employment historyLack of communication tools (No phone, or email)Currently on probationBeltrami County ICWA case - out of home placementRecently released from jail/prisonHomelessnessChemical dependency (Alcohol, Fentanyl, Opioids, Methamphetamine, Buprenorphine)
Cultural Needs (Check all that apply)

Traditional Events / GatheringsOjiwemowin OpportunitiesTraditional / Cultural TeachingsSearching for my clanCounseling from an Elder / HealerTraditional help / advice on intense mattersBeading instructionRicingSugar Bushing
Education & Employment (Check all that apply)

Receiving assistance applying for collegeReceiving assistance with training opportunitiesAssistance with financial aid application (FAFSA)Assistance navigating college / career explorationAssistance with resume developmentConduction practice interviewsLearning new skills for the workplaceInterest in OSHA 30 certificationInterest in First Aid, CPR & Bloodborne Pathogens certificationsLearning new technology skills
Needs of Family & Self (Check all that apply)

Mental health referralsAdult basic education referralsJob application supportAssist in obtaining photo IDInformation / support for navigating family reunificationHousing assistanceSupport Groups (AA, NA, Women / Men)Assistance with transportation (Gas vouchers / bus tokens)Utilizing NWICDC drop-in services (phone, fax, internet)Artistic OpportunitiesLearning new art techniquesVolunteering at NWICDCOther
RELEASE OF INFORMATION

Some agencies and employers will not release information without your consent. We ask all participants to completely read and sign this form. It will remain in your client file for up to one year from the date signed. If at some point during this year you would like to stop this release just provide the NWICDC with a written notice.
I, name authorize the following agencies to release information to Northwest Indian Community development Center. I understand that I am giving up the right to sue all agencies that you allow NWICDC to release information with you on your behalf.
Please select all that apply.

Beltrami County Human ServicesHousing and Redevelopment BemidjiRed Lake Homeless ShelterEmployerStandard HealthMN Rural CEPMN Workforce CenterBi-Cap Housing AssistanceVillage of Hope Homeless ShelterEvergreen Community Services & ShelterProbation OfficerAmerican Indian OICOshkiimaajitahdah (New Beginnings)Mewinzha Ondaadiziike Wiigaming (Healthy Babies Clinic)Other
Fax or photocopies are accepted as originals.
Member Signature (Release of Information)

Clear
PHOTO RELEASE (OPTIONAL)
I authorize Northwest Indian Community Development Center (NWICDC) the use of any photogaphic or electronic reproductions of me for any purpose including but not limited to educational, promotional or social media deemed appropriate by NWICDC. I further acknowledge that my participation is voluntary and that I will not be denied services if I choose not to have my photo taken or used. I understand I might be identifiable through such promotional materials.
Do you authorize NWICDC to use photos of you?

YesNo
Member Signature (Photo Release)

Clear
GIISHPIN DIBENDAAGOZIYAN OMAA (MEMBER RESPONSIBILITES)
1. Gidaa-wiindamaage giishpin ge-aanjbii’igaadegin iniw ezhi-ganoon’igooyan gemaa aandi endaayan.
  (To advise your NWICDC Staff as soon as possible of a new address or telephone number change.)
2. Gidaa-bi-izhaa apii ge-wiidanokiimagwaa NWICDC enokiiwaad. Giishpin bwaanawitooyan gaabige gikendaman ge-bi-ganoonadwaa NWICDC enokiiwaad.
  (To attend and participate cooperatively with NWICDC Staff. If you are unable to participate/attend, notify the appropriate NWICDC program staff as soon as possible.)
3. Gidaa-minwaazomaag minawaa gidaa-mino-doodawaag gakina awiiya apane omaa NWICDC ayaayan.
  (To refrain from using abrasive/threatening language and disruptive/disrespectful behavior while participating in NWICDC programs and services.)
4. Onjii’idim ji-biindigadood awiiya giiwashkwe-minikwewin, gaa-giiwashkwenoozong gemaa gaye miigaazo- abajichiganan. Giishpin bagakendanziwan onjida giiwashkwe’igooyan giga-gagwejimig ji-ni-maajaayan.
  (Alcohol/Drugs/Weapons ARE NOT ALLOWED on the NWICDC premises. If you are under the influence of any substance, you will be asked to leave the premises.)
5. Apane gidabinoojiinyimag gidaa-ganawenimaag omaa NWICDC ayaayan.
  (To supervise your children at all times while at NWICDC or with NWICDC staff.)
Mii sa go gii-agindamaan naa nisidotamaan akina gegoo omaa ezhibii’igaadeg. Mii go gaye gii-nakodamaan onow da- izhichigeyaan.

(I have read and understand the NWICDC member responsibilities and agree that I will abide by all.)

I hereby certify that the statements made on this NWICDC application are complete and accurate to the best of my knowledge.
I agree to cooperate with NWICDC to the best of my ability in acheiving expectations required for programming.

I understand services are available according to eligibility, and funding by program year.
Member Signature (Member Responsibilities)

Clear
EQUAL OPPORTUNITY IS THE LAW
It is against the law for this recipient of Federal financial assistance to discriminate against the following basis:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief. We consider applicants without regard to race, color, creed, religion, national origin, age, sex, political affiliation or belief, marital status, disability, sexual orientation, or status without regard to public assistance. It is our policy to abide by all federal, state, and local laws concerning discrimination; and against any beneficiary of programs financially assisted under Title I of the Workforce investment Act of 1998 (WIA) on the basis of beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title financially assisted program or activity. The recipient must not discriminate in any of the following areas:
- Deciding who will be admitted, or have access to any WIA Title financially assisted program or activity
- Providing opportunities in or treating any person with regard to such a program or activity or
- Making employment decisions in the administration of, or in connection with such a program or activity
What to do if you believe you have experienced discrimination:

If you think that you have been subjected to discrimination under WIA title I financially assisted program or activity you may file a complaint in writing 180 days from the date of the alleged violation with either:

Martin Jennings, Executive Director

Northwest Indian Community Development Center

1819 Bemidji Ave. N

Bemidji, MN, 56601

Phone 218-759-2022

Civil Rights Center (CRC)

U.S. Department of Labor

200 Constitutional Ave NW

Room N-4123

If you file a complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above).

If the recipient does not give you a Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the date on which you received your complaint with the recipient).

If the recipient does not give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with the CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

The above notice to the public applied to the federal programs covered under the Workforce Investment Act (WIA) . Complaints concerning the services provided by non-WIA programs may be processed differently.
TENNESEN WARNING NOTICE
Please read the Tennessen Warning Notice below and the equal opportunity information. Please sign the bottom.

The data we are asking you to provide about yourself is considered private data by Minnesota Statute 13.47 subdivision 2. In order to collect and use this data we must tell you why we need the data, how we intend to use it and any consequences you may experience if you supply the information or not.

Why we need your personal data.
- Your Social Security Number is requested to identify you as a unique individual and to find out wage data to help us determine how well our services helped you.
- Personal characteristics: age, gender, ethnicity, race, disability, and economic status is collected to evaluate our performance and in some cases to determine if you’re eligible for special assistance.
- Veteran status is asked to determine if you are eligible for special services and to evaluate our service delivery.
- Work and education history is used to help you plan your employment and training.
How we intend to use the data and to whom we may share this information:

Work and education history may be shared with prospective employers. In addition to analyzing this data to improve our services, we may share information about you with other employment and training service providers in order to determine what services you may be eligible for and to coordinate services provided to you. Data may be shared with federal and state entities that provide funding for workforce center services. Additionally, other government entities with a legal right to this data may see your information.

Consequences to you if you choose to not provide this information.

You may refuse to supply any or all of this information, you are not legally required to provide any of this information to use workforce development services, not supplying sufficient information may limit our ability to provide you the services you want.

For more information:

DEED Data Practices www.deed.state.mn

Minnesota Data Practices Act www.resivor.leg.state.mn.us/stats/13/

Minnesota Department of Administration Information Policy Analysis Division

Equal Opportunity is the Law

We consider applicants without regard to race, color, creed, religion, national origin, age, sex, political affiliation, or belief, marital status, disability, sexual orientation, or status with regard to public assistance. It is our policy to abide by all federal, state, and local laws concerning discrimination.

Complaint and appeal policy:

If you feel that anyone in our office has treated you unfairly, you have the right to file a complaint. If you have been denied services, you have the right to appeal. If you wish to file a formal complaint or an appeal, please see a staff member for assistance.

I have been made aware of and understand this Tennessen Warning notice. (If you do not understand this statement, please ask that a staff member explain it to you.) I agree that the information on this form may be shared among Minnesota Workforce Center agencies for the purpose of helping me find employment or training. I was presented and have read the equal opportunity information on the Notice to the Public Equal Opportunity is the Law. I also understand that I have the right to file a complaint of discrimination.
Member Signature (Tennessen Warning Notice)

Clear
Should be Empty:

General Membership Form

RELEASE OF INFORMATION

PHOTO RELEASE (OPTIONAL)

GIISHPIN DIBENDAAGOZIYAN OMAA (MEMBER RESPONSIBILITES)

EQUAL OPPORTUNITY IS THE LAW

TENNESEN WARNING NOTICE