Wapas Nah Nee Shaku Sign In

Is this your first time visiting Wapas Nah Nee Shaku (since October 2025)?

Please complete the following intake questions:
In an effort to ensure continuous funding, we ask all participants to complete the following intakes questions at least once a year. This information helps us to share the story and impact of Wapas Nah Nee Shaku. Personal information (such names, address, emails, etc.) will NOT be shared with outside agencies. If you have any questions, concerns, or need help completing the form, please contact one of the NAYA staff members for assistance.

Name

First NameLast Name

Date of Birth

Tribe or any other ancestry you'd like to share? (If none, please put "N/A")

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

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.

Permission/Consent to Photograph, Video, Interviews and Quotations:

Permission/consent to be contacted about other NAYA services & events, and other community events and activities:
NAYA Family Center has my permission contact me or my child about other NAYA Family Center services and events, and other community events and activities by postcards, emails, phone calls, etc.

Permission/Consent to be contacted about other NAYA services & events, and other community events and activities:

Release of Liability/Assumption of Risk:
By participating in the programs and activities of the NAYA Family Center, I agree to hold harmless the NAYA Family Center, and release any and all rights or claims to damages that may arise in connection with or as a result of myself or my child’s participation in the programs and activities of the NAYA Family Center. This release applies to the NAYA Family Center, including any and all officers, agents,employees, volunteers, sponsors, coaches, and/or damages.

Release of Liability/Assumption of Risk:

If you selected "No", please see a member of NAYA's Wapas Nah Nee Shaku to discuss your participation in the scheduled event.

Consent for Transportation in NAYA Vehicles and NAYA Staff Vehicles:
I understand that NAYA Family Center programs and activities may include local and long distance travel, and give permission to the NAYA Family Center to provide transportation. The participant understands and agrees to abide by the following rules with being transported. All participants must be responsible for wearing seat belts at all times. All children under 80 lbs. are required to be properly placed in a child seat or booster seat. Appropriate conduct will be mandatory when being transported. Smoking is not allowed in NAYA Family Center vehicles or personal staff vehicles when being transported. A participant may be subject to suspension of transportation privileges if found in violation of any rules of transportation, or for disobeying the NAYA Family Center staff providing the transportation.

Consent for Transportation in NAYA Vehicles and NAYA Staff Vehicles:

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.

NAYA Internal Information Sharing Agreement:

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.

Consent to Emergency Care and Relevant Information:

Emergency Contact Person 1

First NameLast Name

Relationship to Participant:

Phone Number (Emergency Contact Person 1)

Please enter a valid phone number.Format: (000) 000-0000.

Please list any known allergies below: (If none, please list "N/A")

Please list your preferred name below:

First NameLast Name

How many youth (under age 18) are joining you today?

Youth 1:

First NameLast Name

Age of Youth 1:

Youth 2:

First NameLast Name

Age of Youth 2:

Youth 3:

First NameLast Name

Age of Youth 3:

Youth 4:

First NameLast Name

Age of Youth 4:

Youth 5:

First NameLast Name

Age of Youth 5:

Purpose of today's visit?

Please list the name of the Event/Workshop:

Please list the times you intend to be in the gardens:

Hour Minutes

AM/PM Option

Until

until

Hour Minutes

AM/PM Option

Today's Date

Tell us how long you plan to be in the garden:

Hour Minutes

Purpose of today's Garden visit?(multiselect)

What brings you to the garden?

Please name the 'Garden Event':

Seeds/Plants/Fruits or Vegetables

If you recieved

Wapas Nah Nee Shaku Sign In

NAYA Release & Consent Forms