Pasefika Roots Institute: 2025 - Cycle 2 Application Form

Pasefika After-School Program Cycle 2 Registration Form

Cycle 1 Dates: November 3rd, 2025 - January 17th, 2025

Registration Opens: Wednesday, October 1st, 2025 (No Early Registration)

Late Registration begins: Monday, October 20th, 2025 ($5.00 Late Registration Fee Applies)

All Registrations are Final and Non-Refundable upon submission of this application.

I. Welcome & Program Overview

Malo le Soifua Maua! Welcome to the Pasefika Roots Institute!

We are honored that you are considering joining our Afterschool & Afterwork Language and Cultural Arts Program for Cycle 2. Our mission is to passionately revitalize, preserve, and celebrate Samoan language and cultural arts within our vibrant Alaskan community. Through high-quality educational enrichment and positive youth development, we aim to foster intergenerational learning and strengthen our collective cultural identity.

This program is designed to provide a safe, respectful, and enriching learning environment that supports both academic growth and cultural understanding, consistent with the standards for programs deemed approved and qualified for potential State and Federally Funded support.

Please complete all sections of this form accurately and legibly.

Please provide the details for the individual who will be attending the program.
II. Applicant's Information
1. Applicant’s Full Name (First Middle Last):
2. Applicant’s Preferred Name (if different)
3. Applicant’s Date of Birth

MonthDayYear
4. Applicant’s Age, as of Aug 18 2025
5. Applicant’s Gender
6. Applicant’s Current School (if applicable)
7. Applicant’s Current Grade
8. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

III. Parent/Guardian Information (for Participants Under 18 Years Old)
(If the participant is 18 or older, please proceed to Section IV)
Parent/Guardian 1:
1. Full Name
2. Relationship to Participant
3. Phone Number
4. Email Address
example@example.com
5. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 (Optional):
1. Full Name
2. Relationship to Participant
3. Phone Number
4. Email Address
example@example.com
5. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

IV. Emergency Contact Information

Please provide contact information for two individuals who can be reached in case of an emergency if the primary parent/guardian (for minors) or participant cannot be reached.
Emergency Contact 1:
1. Full Name
2. Relationship to Participant
3. Phone Number
4. Work Phone Number (Optional)
5. Email
6. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2:
1. Full Name
2. Relationship to Participant
3. Phone Number
4. Work Phone Number (Optional)
5. Email
6. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

V. Medical Information & Special Needs

Confidentiality Note: This information is collected solely for the safety and well-being of the participant and will be kept strictly confidential and shared only with essential staff on a need-to-know basis.
YesNo
If “Yes”, please describe:
YesNo
If “Yes”, please describe and outline any necessary instructions for staff:
YesNo
If “Yes”, please describe how we can best support the participant:
YesNo
If “Yes”, please list medication(s) and dosage:
5. Physicians Name (Optional)
6. Physician's Phone Number (Optional):
Please enter a valid phone number.Format: (000) 000-0000.

VI. Cultural & Program-Specific Questions (Optional)

Your insights help us to better serve our community and tailor our programs.
1. What is your connection to Samoan culture (e.g., heritage, family, interest)?
2. What do you hope to learn or experience in this Pasefika Roots Institute program?
3. Are you a member of a Samoan church in Anchorage? If so, which one?

VII. Registration Fees & Discounts

Please determine the applicable registration fee based on the participant's age.

Cycle 1 Registration Fees (August - September 2025):

Child (Age 5 - 10): $50.00 minimum donation

Pre-Teen (Age 11 - 14): $40.00 minimum donation

Teen (Age 15 - 18): $30.00 minimum donation

Adult (Age 19 and above): $50.00 minimum donation

Discounts: 50% Off for Native Samoan Members with a valid Native Samoan ID.

Late Registration Fee: A $5.00 late registration fee will apply for registrations submitted on or after Monday, October 20th, 2025.
1. Participant's Age Category: (e.g., Child, Pre-Teen, Teen, Adult)
YesNo
If "Yes", please attach your valid Native Samoan ID for verification upon payment.

Take a picture of your ID and upload here.
Cancelof
YesNo
The TOTAL CALCULATED FEE will be invoiced according to the above information. Please expect a separate Payment Form to be sent to you, once your application is submitted.

VIII. Waivers & Agreements

Please read each waiver and agreement carefully. Your signature(s) below signify your understanding and acceptance of these terms.
A. Photo and Video Release Waiver: I hereby grant the Pasefika Roots Institute, Jesus is Lord Church, the Native Samoan Corporation, and the Samoan Council Of Pastors & Elders (SCOPE) permission to use photographs and/or video recordings taken of the participant during program activities for promotional, educational, and archival purposes. This may include, but is not limited to, use in brochures, websites, social media, presentations, and reports. I understand that the participant's name will not be publicly identified without additional consent. I waive any right to inspect or approve the finished product.

I have read and agree to the Photo and Video Release Waiver.I do NOT consent to the Photo and Video Release Waiver. (If you select this, aninternal note will be made, and we will do our best to accommodate, though full exclusion from all visual media may not always be possible in group settings.)
B. Liability Waiver and Assumption of Risk:I understand that participation in the Pasefika Roots Institute's After-School Program involves certain inherent risks, including but not limited to, physical activity, minor injuries, or exposure to illness. I acknowledge that while the Institute and Jesus is Lord Church will take reasonable precautions to ensure the safety and well-being of all participants, they cannot guarantee absolute safety. I hereby release, indemnify, and hold harmless the Pasefika Roots Institute, Jesus is Lord Church, the Native Samoan Corporation, the Samoan Council Of Pastors & Elders (SCOPE), and their respective directors, officers, employees, volunteers, and agents from any and all claims, liabilities, damages, or expenses arising from the participant's involvement in the program, except in cases of gross negligence or willful misconduct. In the event of an emergency, I authorize the program staff to seek and obtain necessary medical treatment for the participant.

I have read and agree to the Liability Waiver and Assumption of Risk.
I have read and agree to the Financial Policy Acknowledgment.
D. Code of Conduct Agreement: I understand that the participant is expected to adhere to a respectful and culturally appropriate Code of Conduct while participating in the Pasefika Roots Institute program. This includes showing respect to instructors, elders, fellow students, and the church premises, and following all safety guidelines. Failure to adhere to the code of conduct may result in dismissal from the program without refund.

I have read and agree to the Code of Conduct Agreement.

IX. Payment & Submission Instructions

Registration Fee Due Upon Submission of this Form.

Please select your payment method/referral type below and follow the corresponding instructions:
Standard Payment (Online/In-Person): Please make your payment in the amount of $ Our administrative team will contact you within 1-2 business days after form submission to facilitate payment via online options or direct deposit.Alternatively, you may submit this form and your payment in-person at the Jesus is for office hours or Lord Church office during designated hours. Please call payment inquiries.
Referred from Native Samoan Corporation's Restorative Justice Program: DO NOT make payment directly with this form. Your registration and associated fees will be processed directly through the Samoan Council Of Pastors & Elders(SCOPE SCOPE will communicate directly with you regarding your enrollment status and any specific payment arrangements.
Referred from Anchorage School District (ASD): DO NOT make payment directly with this form. Your registration and associated fees will be processed directly through the Samoan Indigenous Native Agency (SINA) or MAXXON, as exclusive Administrators for the Native Samoan Corporation. SINA/MAXXON will communicate directly with you regarding your enrollment status and any specific payment arrangements.
Upon submission of this form, your registration is considered an application.
X. Acknowledgment & Signature

Final enrollment is confirmed upon successful processing of your registration fee/referral and review of this application.

By signing below, I confirm that I have read, understood, and agree to all the terms and conditions outlined in this registration form, including the waivers and financial policies. I certify that all information provided herein is true and accurate.
Signature of Parent/Guardian (if participant is under 18) or Adult Participant:
Printed Full Name
Date

MonthDayYear
Date
Signature

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