Sep. 16th Culture Night Sign-Up: Drag Bingo!

Culture Night Sign-Up

This registration is for September 16. This Culture Night we will be centering Two-Spirit history and awareness for Suicide Prevention Month with Drag Bingo hosted by Poison Waters! All ages and backgrounds welcome. Registration is required. If you are registering more than one person, please complete and submit a separate registration form for each participant.
Full Name

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Phone Number
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Date of Birth

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What grade will the participant be entering this fall?
Permission Media 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.
I agree:
Consent to Emergency Care and Relevant Information:

In the event of an emergency, 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.
I agree:
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.
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