• American Indian/Alaska Native & Indigenous (AIANI) Services Registration Form

    AIANI is committed to delivering and strengthening culturally responsive services for the Native American and Indigenous community in Los Angeles County. We collect data to advocate effectively for the community’s needs, ensure the delivery of accurate and appropriate services, and identify opportunities to improve overall wellness through our programs and support. Serving Los Angeles County AI/AN & Indigenous Residents Contact: info@aianservices.com
  • Format: (000) 000-0000.
  • Preferred method of contact:
  • The address listed above is a:
  • Date of Birth
     - -
  • Are you a member/descendant of a Federal/State or Indigenous Tribe? (Info purposes only - Not required to access services)
  • Are you a U.S. Veteran?
  • Which type of medical coverage do you have?
  • Ethnicity:
  • Which race/group best describes you (Participant)? (Mark all that apply.)
  • If you identify as Asian, please select all ethnic groups that you identify with:
  • If you identify as Native Hawaiian and/or Pacific Islander, please select all ethnic groups that you identify with:
  • Which gender identity do you (participant) most identify with?
  • Which of the following best describes your (participant) sexual orientation?
  • What is the HIGHEST LEVEL of education that you (Participant) have completed?
  • What is the HIGHEST LEVEL of education that you (Participant) plan to finish?
  • Are you currently in the foster care system?
  • Have you been involved with the juvenile justice system?
  • Please list what services you and/or family would be interested in accessing:
  • How did you hear about us?
  • Would you be interested joining our email list?

  • American Indian/Alaska Native & Indigenous Services

    CONSENT FOR PHOTOGRAPHS OR VIDEO RECORDING 


    We would like to celebrate your participation and/or your child's participation in our programs and activities and are requesting permission to allow staff to take your and/or your child's photo and/or video and record you and/or your child as you participate in activities coordinated by the American Indian/Alaska Native & Indigenous Services staff and contractors. 

    By selecting YES and entering your full name, you, the youth’s parent or guardian, understand that you are giving your consent to allow American Indian/Alaska Native & Indigenous Services Staff to take pictures and/or video record as you and/or your youth participate in the activities. You also understand that these photos and videos of you and of your child may be used for marketing purposes in print publications, presentations, and social media to promote services for the Sacred Path Indigenous Wellness Center. 

     


    You do not have to give consent to photography and/or video recording if you do not wish to do so. This will not affect your participation in our activities and services. 

  • Please Select your response below: Consent for Video & Sound/Voice Recording: Consent for Photography: I (participant) verify that I have selected the appropriate response below, and agree or disagree to the terms.

  • Dual Enrollment Agreement
    By signing up for services with AIANI, you acknowledge and agree that you are also enrolling in services provided by Sacred Path Indigenous Wellness Center. This partnership ensures access to a broader range of resources and support. By completing this application, you consent to the sharing of relevant information between AIANI and Sacred Path Indigenous Wellness Center as necessary to facilitate services, in accordance with applicable privacy laws and regulations.

    The participant (named in previous page) and the authorized representative(s) authorize American Indian/Alaska Native & Indigenous Services to provide support service(s) (referral services and linkages) and cultural activities. I may cancel this consent at any time.

  • I (participant) agree to the above.*
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