CAYC Application (7-12 grade)

Cheyenne & Arapaho Youth Council - Grades 7-12

Yearly Registration Form
Contact Information

Coordinator: Jerilyn LongKnife

Office: (405) 422-7585

Cell: (405) 201-7255

Email: jlongknife@cheyenneandarapaho-nsn.gov
CAYC Background

The Cheyenne & Arapaho Youth Council was sanctioned through the Cheyenne & Arapaho Tribes 32nd Business Committee on March 15th, 2000. The purpose of the CAYC is to uphold and encourage the physical, mental, emotional, social, and spiritual well being of tribal members and Native Americans residing in all communities within the tribal jurisdiction area. Services and ideas will be implemented through planning, coordinating and conduction cultural, educational, and community service activities; to develop a collective and representative voice for Native American youth processing the discipline, courage, and will contribute in building a positive future for our community; and finally, to provide opportunities for youth to interact for fun and fellowship.
Eligibility:
- C&A tribal member (CDIB) or CDIB II
- A student between grades 7 and 12
Duties:
- Attend Youth Council Meetings
- Be a positive influence in your community and among your peers
- Refrain from the use of alcohol, tobacco, and drugs
- Maintain acceptable academic standing
- Conduct behavior as a leader of the Cheyenne and Arapaho Tribes
- Agree to serve a complete 1-year term
- Actively participate in all community service projects and peer discussions.
Failure to abide by the rules and criteria listed will and can result in immediate dismissal from the Cheyenne & Arapaho Youth Council.
Youth Council Application

Please fill out all sections
Full Name

First NameLast Name
Tribal Affiliation
CDIB Number
CDIB or CDIB II

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Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cheyenne & Arapaho District
School
Grade Level
Grade for upcoming Fall
Grade Report & Attendance

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List school sports, clubs, organizations, or extracurricular activities are you involved in?
Shirt Size (unisex sizing)
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Medical & Emergency Information
Emergency Contact #1 Name

First NameLast Name
Emergency Contact #1 Relationship to Youth
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Relationship to Youth
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Provider Name
ID Number & Group Number
Insurance ID (front & back)

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Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
The child has my permission to self administer the following prescription(s) or over the counter medication(s) as needed or prescribed.
Acknowledgment
- I agree to follow the Cheyenne & Arapaho Youth Council's guidelines, rules, and policies.
- I authorize my child to join all activities and discussions, including social and health topics.
- I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
- Any repeated offense by the youth may result in suspension or expulsion.
- Parent/Guardian registered in this form has legal custody over the child.
- I allow my child to ride any vehicle that is related to the group's activities, provided that there's an adult on board.
- For medical emergencies, I allow the medical team of this organization to take care of my child.
- I release this organization from any and all liability from accident or injury to the child during the organization related events.
Communication
To stay up to date with the Cheyenne & Arapaho Youth Council, please download the 'GroupMe' app to BOTH a parent device and youth device.
Parent/Guardian Signature
Youth Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Cheyenne & Arapaho Youth Council - Grades 7-12

CAYC Background

Failure to abide by the rules and criteria listed will and can result in immediate dismissal from the Cheyenne & Arapaho Youth Council.

Youth Council Application

Parent/Guardian Information

Medical & Emergency Information

Acknowledgment

Communication