TSSSA Registration Form

  • Two-Spirit Safe Space Alliance

    NAYA's Two Spirit Safe Space Alliance provides a safe and supportive environment for 2SLGBTQ+ youth aged 13-19 where they can connect with others who share similar experiences, and have fun!
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • NAYA Legal Consents and Releases

    Please review with your participant/student as the parent/guardian. All releases and consents must be completed and signed by a parent or legal guardian, or an adult participant who is 18 years or older.

  • Permission/consent to photograph, video, interviews and quotations:

    I give consent for myself or my child to participate in NAYA Family Center marketing activities, including interviews, the use of quotes, and the taking of photographs, movies or video tapes by NAYA Family Center employees. I grant NAYA Family Center the right to edit, use, and reuse said products for non-profit marketing purposes including use in NAYA Family Center grant writing and marketing in print, on the internet, and all other forms of media. I also hereby release NAYA Family Center and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

  • Consent to Emergency Care and Relevant Information:

    In the event of an emergency, if reasonable attempts to contact persons listed are unsuccessful, I give consent to the NAYA Family Center to transport myself or my child to the doctor or to the Emergency Medical Department of the nearest hospital. If my doctor cannot be contacted, all medical treatments deemed necessary by the attending licensed physician, including examinations, anesthesia, operations, and diagnostic procedures, may be administered. I further acknowledge that I will be responsible for all fees and costs associated with the medical treatment that are not covered by my insurance.

  • NAYA Internal Information Sharing Agreement:

    Information sharing within NAYA services, or internal information sharing between staff, is often necessary in order to better serve the participant and family. Please indicate your agreement for NAYA staff to share your information within NAYA programs as needed to provide services. By acknowledging Yes, you understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.

  • Non-Discrimination Agreement

    We, the organizers, parents, guardians, participants, students, teachers, and staff of NAYA Youth and Family Center, hereby pledge to create an environment that is inclusive, respectful, and free from discrimination of any kind. We believe in the inherent dignity and worth of every individual and are committed to upholding the following principles:

    Equal Opportunity: We affirm that all individuals, regardless of race, color, ethnicity, nationality, religion, gender, gender identity, sexual orientation, disability, socio-economic status, or any other characteristic, have the right to equal opportunities and treatment within our program.
    Respect and Dignity: We will treat each other with respect, dignity, and empathy. We recognize that everyone brings unique perspectives, experiences, and talents to our community, and we value this diversity.
    Non-Discrimination: We will not tolerate any form of discrimination, harassment, or prejudice. This includes but is not limited to actions or language that is racist, sexist, homophobic, transphobic, ableist, or otherwise discriminatory.
    Zero-Tolerance for Isms and Phobias: We have a zero-tolerance policy towards all forms of isms (such as racism, sexism, ableism, etc.) and phobias (such as homophobia, transphobia, etc.). Any behavior or language promoting such ideologies will not be tolerated and will result in immediate disciplinary action.
    Decolonization: We acknowledge the historical and ongoing impacts of colonization on marginalized communities. We commit to challenging colonial structures, narratives, and practices within our program. This includes centering Indigenous knowledge, perspectives, and voices, as well as amplifying the experiences of marginalized groups.
    Inclusivity: We are committed to creating an inclusive environment where all individuals feel welcome, valued, and supported. We will strive to foster an atmosphere of openness, acceptance, and understanding.
    Accessibility: We will make reasonable accommodations to ensure that our program is accessible to individuals with disabilities. We will also consider the diverse needs of participants and work to address any barriers to participation.
    Conflict Resolution: In the event of conflicts or concerns related to discrimination or harassment, we will address them promptly and fairly. We encourage open communication and constructive dialogue to resolve issues and promote mutual understanding.
    By agreeing below, we affirm our commitment to these principles and pledge to uphold them throughout the duration of participating in Two Spirit Safe Space Alliance events.

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