Community Interest Membership

Community Interest Membership Form

Northwest Indian Community Development Center

Miigwech for seeking membership at Northwest Indian Community Development Center (NWICDC) and working with us to build healthy individuals, families, and communities.
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Name

First NameLast Name
Current Mailing Address
City
Zip
County
Date of Birth

MonthDayYear
Date
Age
Are you enrolled in a federally recognized tribe?
If yes, what tribe or native nation?
If no, are you a descendant? Which Tribe?
Phone Number
Email
example@example.com
Areas of interest you would like to receive future information on:

Education and/or Employment SupportParenting Education, Family Reunification, Free Doula ServicesRe-Entry From Incarceration and/or Recovery SupportHousing ResourcesCultural and Traditional Healing EventsIndigenous Arts and Crafts
NWICDC Member Responsibilities

1) Attend and participate cooperatively with NWICDC staff; advise of new address or phone number

2) Refrain from using abrasive/threatening language and disruptive/disrespectful behavior while participating in NWICDC programs and services

3)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

4) Supervise your children at all times while at NWICDC or with NWICDC staff

5) Be a good guide by sharing your gifts and being respectful to Aazhoomon staff, faculty and members

I have read and understand the NWICDC member responsibilities. I 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.
Applicant Signature

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PHOTO RELEASE (Optional)

I authorize Northwest Indian Community Development Center (NWICDC) the use of any photographic or electronic reproductions of me for any purpose, which may include but is not limited to the following: education, promotional or social media materials. I 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.
Applicant Signature

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PHOTO RELEASE FOR MINOR CHILD (Optional)

I authorize Northwest Indian Community Development Center (NWICDC) the use of any photographic or electronic reproductions of my child or child under my legal care, for any purpose, which may include butis not limited to the following: education, promotional or social media materials. I acknowledge that participation is voluntary and that I will not be denied services if I choose not to authorize the photo release for my child or child under my legal care. I understand my child or child under my legal care might be identifiable through such promotional materials. I hereby certify that I am the legal parent or custodian for the child applicant.
Applicant Signature

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