Future Inspired Native American Leaders Application

Future Forward
Join the Future Inspired Native American Leaders Program!
What is it?
An exciting program that prepares American Indian high school young men to become college and
career ready and learn about their culture!
Who is eligible?
All American Indian or Alaskan Native male high school students attending high school within Maricopa
County.
Why should I participate?
You will learn about college and career opportunities, how to become successful in your personal life,
and build relationships with other young native men and community leaders!
What will I do?
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Develop relationships with other American Indian young men from across Maricopa County.
Attend Monthly Saturday Academies to learn about college and career readiness, culture as a
strength, and personal development.
Participate in additional activities throughout the month related to college, careers, and culture.
Receive mentoring and direct access to valuable services for you and your family.
Register today!
1. Fill out the attached consent forms.
2. Return packet to the Phoenix Indian Center either by mail, fax, or email attachment.
Phoenix Indian Center
4520 N Central Ave, Suite 250
Phoenix, AZ 85012
www.phxindcenter.com
Fax: 602-274-7486
Email: kpolsean@phxindcenter.org
Call the Phoenix Indian Center at 602-264-6468 ext. 2305, email kpolsean@phxindcenter.org or
visit our website at www.phxindcenter.org if you have any questions!
Future Forward
Dear Future Participant and Family,
The Phoenix Indian Center would like to invite you to participate in an exciting program, Future
Inspired Native American Leaders (F.I.N.A.L.), designed for American Indian high school young men
in Maricopa County. This program prepares American Indian young men to become college and
career ready.
We have a strong team creating this program that includes the Phoenix Indian Center, Mesa
Public School Native American Program, Phoenix Union High School District Native American
Program, Native American Connections and Native Health. We need you to complete the team you’ll have the opportunity to provide input and help build this important program!
We offer monthly Saturday Academies and multiple events throughout the month focused on
college, careers, and culture. Students will also receive mentoring and support from the Youth
Development Specialist at the Phoenix Indian Center.
To enroll in this FREE program, please sign and complete the attached form and return it
immediately. We look forward to seeing you soon!
Thank you,
Kalah Polsean
Youth Development Specialist
Phoenix Indian Center
602-264-6768 ext. 2305
kpolsean@phxindcenter.org
www.phxindcenter.com
Future Forward
2014-2015 Saturday Academy Schedule
September 13
October 11
9:00 AM -1:00 PM
Saturday Academy
Program Name brainstorming & Final Selection
Career Assessment Review & Analyses
8:00 AM – 1:00 PM
Saturday Academy
Volunteerism – Native American Recognition Days Parade; Phoenix Indian
School Band Building Open House
November 15
9:00 AM – 1:00 PM
Saturday Academy
College Readiness and Career Readiness; What will it take to be
successful in either opportunity? Designing a Logo!
Culture as a Strength; Transitioning to Adulthood - Recognizing
Development
December 13
9:00 AM – 1:00 PM
Saturday Academy
Winter Celebration and Holiday Luncheon: What makes a
great role model?; Learn about archery; play native games
and enjoy Winter storytelling.
January 10
9:00 AM – 1:00 PM
Saturday Academy
Crafting a powerful “Look at Me” resume and how to correctly complete
an application. Technology in the workplace.
Culture as a Strength; Balancing between two worlds
February 28
9:00 AM – 3:00 PM
Youth Leadership Day
2014 Workshops: Tracts Include College Affordability : How to get the
best bang for your buck; How to complete a FASFA application; How to
research scholarship opportunities and when to apply for them; Positive
Habits Build Traditions; Building Soft Skills ; Cultural Resiliency as
Prevention; Parent Workshops.
March 14
9:00 AM – 1:00 PM
Saturday Academy
Gathering of Native Americans
April 11
9:00 AM – 1:00 PM
Saturday Academy
Acing the Interview; interviewing tips
Cultural Values as a Strength: Wellness and Health
May 9
9:00 AM – 1:00 PM
Saturday Academy
Apprenticeships, Internships and Mentors, Oh My! (Hands On)
Cultural Values as a Strength: Wellness and Health
June 13
9:00 AM – 1:00 PM
Saturday Academy
Celebration and Can I Afford this? - Financially Fit for Youth – checking
vs. savings accounts; how to build and a credit score and maintain a good
credit score and personal budget; the pitfalls of credit cards
Cultural Values as Strength: Wellness and Health
Culture is embedded in all Saturday Academies. E.g., Talking Circles, Language and Literature, Rites of
Passage, Ceremony, Fatherhood, etc.
Future Forward
Future Inspired Native American Leaders Application Checklist
Complete the following forms to enroll in the Future Inspired Native American Leaders Program.
o Registration Form (Page 5)
o Participant Agreement (Page 6)
o Phoenix Indian Center Photo / Video / Audio / Written Information Release (Page 7)
o Evaluation Permission Form (Page 8)
o Demographic Survey (Page 9 &10)
o College Interest Survey (Page 11&12)
Return packet to the Phoenix Indian Center by mail, fax, email attachment, or in-person.
Phoenix Indian Center
4520 N Central Ave, Suite 250
Phoenix, AZ 85012
www.phxindcenter.com
Fax: 602-274-7486
Email: kpolsean@phxindcenter.org
Future Forward
FUTURE INSPIRED NATIVE AMERICAN LEADERS REGISTRATION FORM
Student Information
Student Name: ______________________________________________________ Grade: ________ Gender: ________
School: ______________________________________ School District: ________________________________________
Phone Number: ________________________________ Email :_______________________________________________
Home Address: _____________________________________________________________________________________
Tribal Affiliation: _____________________________________________________________________________________
Parent/Guardian Information
Parent/Guardian Name: ______________________________________________________________________________
Phone Number: ________________________________ Email: _______________________________________________
Transportation Agreement
By signing below, I hereby authorize and give full consent to the PHOENIX INDIAN CENTER, INC. to transport my child.
______________________________________
______________________________________
Printed Name of Student
Printed Name of Parent/Guardian
________________________ _____________
___________________________ _________
Signature of Student
Signature of Parent/Guardian
Date
Date
Participant Release, Indemnity, and Assumption of Risk Statement
This Release, Indemnity, and Assumption of Risk statement covers all activities, events, sessions, meals, occurrences,
participation, observation, and travel between activities, associated with this project. I hereby give permission for my child to
participate. For my child, I agree to assume the risk of any events associated with my child’s participation, observation, or
other activities that may result in any harm, injury, illness, damage or loss to my child. I hereby release, waive, and hold
harmless Phoenix Indian Center, or other organizations involved in the program or any of these organizations agents,
personnel or volunteers from any claims, liability, or responsibility for any such injury, illness, damage or loss. I understand the
activities are voluntary, and I agree to accept the responsibility for my child’s personal safety and participation in the
program. I consent to the provision of emergency medical treatment for my child to the extent the treatment is necessary in
the medical opinion of the doctor rendering the treatment. If I have any concerns about my child’s ability to participate in
any event or activity associated with the Phoenix Indian Center, I agree to discuss my concerns with my child’s physician
before signing this form.
Emergency Contact/ Medical Information
Hospital/Clinic Preference: ________________________________________________________________
Physician’s Name: _________________________________ Phone: ________________________________
Allergies/Special Health Considerations: ______________________________________________________
Legal Guardian’s Name (Print): ___________________________________________________________
Relationship: ___________________________________________________________________________
Signature: _________________________________________
Date: __________________________
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.
Future Forward
FUTURE INSPIRED NATIVE AMERICAN LEADERS REGISTRATION FORM CONT.
Phoenix Indian Center Staff Responsibilities
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Explanation of available program activities to eligible participants
Assistance with developing goals for eligible participants
Education, advisement and assistance to achieve program goals as identified
Referral for outside services not provided by program/agency
Coordination of services with other agencies related to participant’s progress
Program Participant Responsibilities
 Showing up on-time for all schedules activities/events/classes. For any activity with a stipend
attached (such as the Career Exploration Summer Session), any time or days missed during the
program will result in a decrease in the stipend amount.
 Notifying staff when you will be late or absent from any scheduled class of activity
 Informing staff of contact information changes as well as concerns related to the program or
activities; e.g. transportation, housing, personal issues, etc.
 Agreeing to abide by all rules and standards, established by the Phoenix Indian Center Inc. (e.g.
no smoking in the building, inappropriate language, improper use of equipment, no drugs, alcohol,
and firearms allowed on the premises.)
This agreement will remain in effect for the duration of the program. The Program Manager will be
advised of any violations of agreement and appropriate action may be taken to remedy the situation,
including family discussions or possible suspension from the program.
I have read and understand the terms and conditions of this agreement and further understand my
responsibilities as a program participant. I understand this authorization shall be in effect for the
direction of my acceptance and participation in the program. By signing below, you indicate that you
want to participate in this exciting program and that your parent/guardian supports your participation.
________________________________________
Printed Name of Student
_________________________________________
Printed Name of Parent/Guardian
__________________________ _____________ ______________________________ __________
Signature of Student
Date
Signature of Parent/Guardian
Date
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.
Future Forward
PHOENIX INDIAN CENTER, INC.
Photo / Video / Audio / Written information Release
I hereby authorize and give full consent to PHOENIX INDIAN CENTER, INC. to reproduce, publish, display
and/or copyright all written information, live broadcasts, still or motion photographs/videos and/or voice
recordings taken by them or agents, in which I appear.
I release PHOENIX INDIAN CENTER, INC. and its funders, representatives and assignees from any and all
claims, demands and causes of action of every nature and kind arising out of or connected with the use of
these broadcasts, photographs, videos and/or voice recordings.
I further agree that PHOENIX INDIAN CENTER, INC. may use or cause to be used, these items for any and
all exhibitions, public display, publications, commercial art and advertising purposes without limitation or
reservation or any fee.
Student Information
Signed: __________________________
Print Name:
__________________________
Address:
__________________________
Date: ________________
__________________________
Phone:
__________________________
Email:
__________________________
If person signing is a minor, legal guardian must sign below:
Parent/Legal Guardian: _________________________ Date: ________________
Print Name:
_________________________
Address:
_________________________
_________________________
Phone:
_________________________
Email:
_________________________
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.
Future Forward
Future Inspired Native American Leaders Evaluation Permission Form
Dear Parent/Guardian:
As you know, your child is participating in the Phoenix Indian Center’s Forward Promise project this year.
This is an exciting project designed for American Indian high school boys attending schools within the
Phoenix metropolitan area. I am conducting an external evaluation of the project to better understand the
program’s impact on helping the boys prepare for college and careers.. The project provides a variety of
activities for participating youth and their families throughout the year. Here is a summary of the type of
information we’d like to collect:
1.) Satisfaction feedback on events attended
2.) Student information (grade, age, tribal affiliation, educational aspirations, and school data).
3.) Specific college and career readiness knowledge and skills
In addition, we will be conducting group interviews with the students to get a better sense of how well they
liked (or not!) the program.
I will be conducting the study and am a professional, independent evaluator from Arizona Evaluation and
Research Associates. All student data results are confidential, and reports of the study will not include the
names or any personally identifying information of any children. Participation in the evaluation is
completely voluntary. If your student is interested, we will need your permission to continue. If you are
willing to have your child participate in this study, please sign below and return the form by your student.
If you have any questions about this project, please feel free to call me at 602-237-0719 or email me at
mwhite@azera.org
Sincerely,
Mary Aleta White, Ph.D.
Project Evaluator
--------------------------------------------------------------------------------------------------------------------Student’s Name _____________________________________________
___
I understand the scope of this project and give my consent for my child to complete the project
surveys throughout the year.
Parent Signature _______________________________________________________________
Parent Printed Name _____________________________________________
Date ________
*-*-*-*
Student’s Name _____________________________________________
___
I understand the scope of this project and do not give my consent for my child to complete the
project surveys throughout the year.
Parent Signature _______________________________________________________________
Parent Printed Name _____________________________________________
Date ________
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.
Future Forward
Future Inspired Native American Leaders Demographic Survey
1. Student Name:
2. Grade:
3. School:
4. Tribal Affiliation(s):
5. Age:
6. Who is your primary caregiver?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Tribe Enrolled (if enrolled):
Mother
Father
Adoptive or Foster Parent
Grandmother
Grandfather
Auntie
Uncle
Cousin
Brother
Sister
Self
Other (describe) _______________________________________________________
7. What is the highest degree or level of school your primary caregiver has completed?
a. No schooling completed
b. Nursery school to 8th grade
c. Some high school, no diploma
d. High school graduate, diploma or the equivalent (for example: GED)
e. Some college credit, no degree
f. Trade/technical/vocational training
g. Associate degree
h. Bachelor’s degree
i. Master’s degree
j. Professional degree
k. Doctorate degree
8. Please indicate the employment status of your primary caregiver
a. Employed for wages
b. Self-employed
c. Out of work and looking for work
d. Out of work but not currently looking for work
e. A homemaker
f. A student
g. Military
h. Retired
i. Unable to work
Future Forward
Future Inspired Native American Leaders Demographic Survey Cont.
9. What is your current household income in U.S. dollars?
a. Under $10,000
b. $10,000 - $19,999
c. $20,000 - $29,999
d. $30,000 - $39,999
e. $40,000 - $49,999
f. $50,000 - $74,999
g. $75,000 - $99,999
h. $100,000 - $150,000
i. Over $150,000
j. Would rather not say
10. What is the size of your household? (All people who live with you)
a. 1 person
b. 2 people
c. 3 people
d. 4 people
e. 5 people
f. 6 people
g. 7 people
h. 8 or more people
11. How many children under 18 years old live in your household?
a. None
b. 1
c. 2
d. 3
e. 4 or more
12. Does any member of your household receive Food Stamps
a. Yes
b. No
c. Unsure
13. What is the primary language spoken at home?
14. Do you take care of a younger sibling? If yes, how often and normally what times of the day or
evening?
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.
Future Forward
Future Inspired Native American Leaders College Interest Survey
1. Student Name:
2. Grade:
3. School:
4. What grades do you usually receive in school?
What is your GPA?
5. Where do you access the Internet?
6. Are you aware of course requirements for high school graduation?
7. Check any of the following that apply to you so that we can better help you in this program:
o I have missed school several times
o I am in foster care or a ward of court
o I have a physical disability
o I have a learning disability
o A member of my household is in jail or prison
o I am the first one in my family to go to college
o A member of my household is on active duty
o A member of my household is unemployed
o A member of my household is seriously ill
o I am not sure if I will qualify for financial aid
o I have responsibilities outside of school (i.e. work)
o I have a child
o Other (please describe) __________________________________________________________
8. What are your plans after high school?
o Associate’s degree (2-year degree)
o Bachelor’s degree (4-year degree)
o Apprenticeship
o Certification
o Enter the workforce immediately after graduation
o Join the military
o Other (please describe) ___________________________________________________________
9. Are you aware of admissions requirements at the school you plan to attend?
o Check if you have or are planning on doing any of the following: (check all that apply)
o Take college prep, AP, or honors level courses
o Learn about admissions requirements
o File a Free Application for Federal Student Aid (FAFSA)
o Complete college applications
o Loot at housing options at school you plan to attend.
o Visit college campuses to learn more
o Take ACT or SAT one or more times
o Learn about what types and how much financial aid and scholarships you will need to pay for
college
o Earn college credits while in high school
o Work with a program that can guide you through the college and financial aid application
process.
Future Forward
Future Inspired Native American Leaders College Interest Survey Cont.
10. I would like more information and support from Phoenix Indian Center about: (Check all that apply)
o How to pay for college or other training
o Finding about different options for education, training, and careers beyond high school
o Which colleges or program to apply to
o Identifying who can provide a recommendation
o Making sure I am academically ready for college of work
o How and when to apply for financial aid & scholarships
o Resolving an issue that could prevent you from taking part in education or training beyond high
school
o How to get ready for college admissions tests
o Identifying who can help me through this process
o Obtaining fee waivers
o How to get a job
o Resume writing
o Assistance on interviewing
o Other (please describe) ___________________________________________________________
11. Please list the schools or program you are considering applying for admissions.
12. List the major areas of study or training programs that interest you.
13. What made you decide on those areas?
14. Do you feel you are academically ready for college-level coursework?
15. If not, what steps do you need to take to prepare for college/major?
16. Have you met or are you planning to meet with you guidance counselor.
17. Do you need any other type of support? If yes, please specify.
Remember, this program is here to support you. The more information you provide, allows us to create a
program to best meet your needs.
Mail, Fax or Email completed form immediately.
Upon receipt of form you will be contacted for the next steps.