Two Feathers Training Permission Slip

Two Feathers QPR Training

Youth Training
Event Details

The Karuk Education Department received a Native Connections, SAMHSA grant in September of 2024. This grant focuses on mental health, suicide prevention and opioid awareness. As part of this grant, we are to have a minimun of 12 youth trained as "Peer Support Specialists" under an upcoming Peer-Based Mentorship program we are launching. Two Feathers has graciously offered to provide this training to our youth on September 9, 2026 in Orleans. By signing the permission slip below, you are giving permission for your child to attend this training. The training will be held in Orleans on Sept. 9th, 2026 at 4:30pm. Once you have completed the registration/consent, we will reach out to confirm registration and disclose the location of the event. If you have any questions, please contact Roseann Ritchison at rritchison@karuk.us or 530-643-3907 **Spaces are limited to 25 youth and 10 adult chaperones**
Participant Details
Participant Name

Child's First NameChild's Last Name
City/Town of Residence
Age
In Case of Emergency Contact 1
Parent/Legal Guardian Name

First NameLast Name
Relationship to the Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In Case of Emergency Contact 2
Parent/Legal Guardian Name

First NameLast Name
Relationship to the Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical and Transport Information
Additional information/updates for the Event Organizer to be aware of? (Please detail any current medical or other needs).
Consent
I have noted the information and give permission for my child to participate in and be transported to the above event.
Parent/guardian's signature
Date Signed

MonthDayYear
Date
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Two Feathers QPR Training

Event Details

Participant Details

In Case of Emergency Contact 1

In Case of Emergency Contact 2

Medical and Transport Information

Consent