GONA (Gathering of Native Americans) 2017
THIS IS A DRUG, ALCOHOL, AND TOBACCO FREE EVENT!
Youth Registration Packet
United Indian Health Services, Inc. K’ol ho koom’mo program is proud to announce a
GONA (Gathering of Native Americans) event to be held at Humboldt State University in
Arcata, CA. Youth participants will be attending this event from Tuesday, July 25 to
Friday afternoon, July 28, 2017.
The GONA event is focused on increasing the strengths of youth, healing the past, and
building the future. Over years, thousands of GONAs have been held all over North America.
Hundreds of thousands of folks have experienced GONA with their family, tribe, or community.
Through the four components of Belonging, Mastery, Interdependence, and Generosity we
start to examine how to be an active participant in our own life and community wellness.
Native American youth ages 12-17 are eligible to participate. Registration is based on a
first-come, first served basis.
If you have any questions or need more information,
Please contact Sarah Scott at UIHS in Arcata CA at 707-825-4151 or
e-mail at [email protected]. Please send registration
packet to UIHS, 1600 Weeot Way Arcata CA, 95521 or
you can drop off this completed packet at any
UIHS clinic site in Humboldt or Del Norte County.
Packets may also be faxed to (707) 825-5055
Registration deadline is Wednesday July 14th, 2017.
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GONA (Gathering of Native Americans) 2017
Youth Registration Packet
Youth Information and Contacts
Child’s Name:_______________________________________
Age:______ Gender: ____________
Name of Parent/Guardian:_____________________________________________________
Parent/Guardian Contact Phone: ________________________________________________
Child’s Address:_______________________________________________________________
Child’s Tribal Affiliation __________________________ T-Shirt Size_____________________
Schedule
Tuesday July 25th
HSU- 12pm
Dorms available
Wed July 26th
9am – 5pm GONA
HSU Dorms, evening activities for youth
Thurs July 27st
9am- 5pm GONA
HSU Dorms, evening activities for youth
Friday July 28nd
9am- 3pm GONA ends
Transportation
Limited transportation to and from the GONA event is available for youth living in the UIHS
service area. Transportation is on a first come first serve basis. Transportation is only available
on the evening of Tuesday, July 25th for the first night of the dorms, and at the end of the last
day of the event (Friday, July 28th). Youth will be staying on campus with other youth
participants for three nights (Tuesday, Wednesday, and Thursday nights).
Does your child need transportation to and from the event? YES NO
If answered yes, where: ______________________________________
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Lodging
Youth will stay in the dorms at the Redwood Hall at HSU, where the GONA event is being held.
Youth will be supervised at all times by UIHS staff and hired chaperones.
What will be provided: Bed linens, blankets, pillow, towels, and soap will be provided.
What to bring:
4 days of clothing. Light jacket, Sweatshirt/sweaters, Long sleeve shirts, T-shirts, Tank tops,
Underwear, Jeans/pants, Shorts, Sweat pants or warm up pants, Pajamas, Shoes, Socks,
Toothbrush, toothbrush container, and toothpaste, Shampoo and conditioner, Hairbrush/comb,
Towel, Bag for dirty clothes, Swimsuit ect.
Please DO NOT Bring: IPODS, MP3 players, CD players, tablets, cell phones or any other
electronics, money or candy. No knives or weapons. E-cigarettes are not allowed. UIHS will not
be responsible for any items that are lost, stolen, or damaged at the event.
Consent to Search: All youth will be searched for non-allowable items before they will be
assigned to a room. If any items are found those items will be held by UIHS staff. If items such
as tobacco products, e-cigarettes, drugs or alcohol are found, youth will be sent home.
Meals
All youth participants will be provided with three meals per day at the HSU campus cafeteria.
Snacks will be provided at the event.
THIS IS A DRUG, ALCOHOL, AND COMMERCIAL TOBACCO FREE EVENT!
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Parent/Guardian Consent for GONA
I hereby give my minor child ____________________________________ permission
to attend the GONA event at Humboldt State University from 3pm July 25, 2017 to 3pm
July 28, 2017. This participation will consist of a 4 - day GONA curriculum that addresses healing
as a community through participation in small group team-building activities, art and cultural
activities, and lessons led by adult facilitators. My child will also participate in evening
recreational and cultural activities on campus.____(initial)
Early Dismissal:
I understand that I will be contacted to pick up my child for any illness, fighting or behavior
problems, and use of any substance such as drugs, alcohol, tobacco, or e-cigarettes. UIHS will
NOT be able to provide transportation. ____(initial)
Photo/Video/Audio/Name Release Form — Minor:
I grant permission to use photographic and/or video images and/or audio recordings and/or
name of my minor child(ren), without compensation, in print, video, online, and/or any other
analog or digital media designed for news, informational or educational purposes related to the
United Indian Health Services, Inc. programs and services.
Child(ren)’s name(s) ________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Print parent or guardian name ____________________________________________________________________________________________________
Address____________________________________________________________________________________________________________________________________
Phone ______________________________________________________________________________________________________________________________________
Parent Signature _______________________________________________________________________________________________________________________
Date__________________________________________________
Emergency Contact:
If you need to contact your child due to an emergency during the event, please call:
GONA Event Supervisor, Rob England at (707) 845-4940.
***NOTE: All medications must be provided to staff during the check-in process.
Medications will be safely and properly stored and will be dispensed by staff to minor child as
required.
Parent/Guardian
Signature: _______________________________Date:_________________________
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Medical Authorization for Treatment of a Minor
I hereby authorize United Indian Health Services, Inc., as an agent for the undersigned
to consent to any x-ray examination, anesthetics, medical, surgical diagnosis or treatment and
hospital care which is deemed advisable by, and is to be rendered under the general or special
supervision of any physician and surgeon licensed under the provision of the Medical Practices
Act or the medical staff of any hospital whether such diagnosis or treatment is rendered at the
office of said physician or at the said hospital.
It is understood that this authorization is given in advance of any specific diagnosis,
treatment or hospital care being required but is given to provide authority and power on the
part of our aforesaid agent or agents to give specific consent to any and all such diagnosis,
treatment or hospital care which aforementioned physician in the exercise of his/her best
judgment may deem advisable.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of
California. I hereby authorize any hospital which has provided treatment to the above named
minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender
physical custody of such minor to the above named agent upon completion of treatment. This
authorization is given pursuant to Section 1283 of the Health Safety code of California.
These authorizations shall remain effective through July 28th, 2017 unless sooner
revoked in writing and delivered to said agent.
Child’s Name ________________________________________________________________
Parent/Guardian Name (print) ________________________________________________
Parent/Guardian Signature:_________________________________Date:_______________
Emergency Contact _____________________________ Phone _______________________
Medical History
Child’s doctor ______________________________________________________________
Any medical conditions to be aware of ___________________________________________
Food/medicine allergies: ______________________________________________________
Medication:
If your child will require medication during summer camp, please provide the following
information:
Type of Medication Dose Amount/ Frequency
Special Instructions
______________________________________________________________________________
______________________________________________________________________________
Insurance Information
Insured’s Name ______________________________________________________________
Name of policy ______________________________________________________________
Policy Number ______________________________________________________________
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Informed Consent for Participation in Evaluation of
Ko’l ho koom’ mo – Working Together Program
Connie Stewart, Executive Director
California Center for Rural Policy, Humboldt State University
Why are we asking for your permission?
Because you have participated in a training or presentation sponsored by the Ko’l ho koom’ mo –
Working Together program, your feedback is valuable to program developers and you are being asked to
participate in a program evaluation of the training. Your participation in this evaluation is voluntary.
Your decision to participate or not in the program evaluation will not affect your involvement with the
Ko’l ho koom’ mo program.
PURPOSE OF THE PROGRAM EVALUATION – What is being evaluated?
The program evaluation will ask you to answer questions about what knowledge or skills you may have
gained as a result of participating in the training or presentation that relates to suicide prevention
among Native youth. You may also be asked to be a part of a talking circle later in the year to
understand how the training might have impacted you.
PROCEDURES INVOLVED IN PARTICIPATING IN THE PROGRAM EVALUATION – what will you have to
do?
If you volunteer to participate in this evaluation, you will be asked to complete brief surveys after each
training in which you participate. The survey will ask questions about you have learned from the
training/presentation, what you think you can do with what you have learned, and questions about how
the training was conducted. Within 6-9 months, you may be asked to participate in a talking circle with
other youth program participants, to understand what impact the program had had on them.
POTENTIAL RISKS – what are the risks and possible problems if you participate in the program
evaluation?
The possible risk involved may be temporary feelings of emotional discomfort related to the topic of
suicide prevention. The training facilitators are trained to help participants be comfortable and feel
supported.
POTENTIAL BENEFITS– how will this evaluation help you or your community?
Benefits to you include increased understanding and documentation of the impact of Ko’l ho koom’ mo
on participants regarding what works well to help prevent suicide in American Indian youth. The
findings will be used to inform other groups, community and tribal leaders, researchers and funders on
effective suicide prevention strategies and methods for working with American Indian youth and
communities.
PAYMENT FOR PARTICIPATION– What will you receive?
If you are selected for a talking circle, you will receive a $25 gift certificate if you are not being paid by
your employer to attend as a part of your job. You will not receive financial payment for completing
evaluation surveys.
CONFIDENTIALITY– Who will know about what you say?
Your responses to evaluation questions asked in this project will be anonymous. The surveys that you
take will not have your name on it and cannot be connected to you in any way to anyone outside this
project. If you participate in a focus group, your responses will be recorded on a form that does not
have your name on it.
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PARTICIPATION AND WITHDRAWAL– Can you stop answering if you don’t want to continue?
Your participation in this evaluation is VOLUNTARY. Your decision whether or not to participate will not
affect your relationship with the program. If you agree to participate, you are free to withdraw consent
and discontinue participation at any time.
IDENTIFICATION OF PROGRAM EVALUATORS– Who can I talk to about this?
If you have any questions or concerns about your participation in this evaluation, please feel free to
contact Connie Stewart, Primary Investigator for Ko’l ho koom’ mo (Working Together) Project:
Connie Stewart, Executive Director
California Center for Rural Policy
Humboldt State University
1 Harpst Street
Arcata, CA 95521
(707) 826-3402
[email protected]
RIGHTS OF PARTICIPANTS– What are my rights as a participant in this evaluation?
You may withdraw consent at any time and discontinue participation without penalty. You are not
waiving any legal claims, rights or remedies because of your participation in this program evaluation. If
you have any concerns or any dissatisfaction with any part of this study, you may contact the IRB Chair,
Dr. Ethan Gahtan, at [email protected] or (707) 826-4545. If you have questions about your rights as
a participant, report them to the Humboldt State University Interim Dean of Research, Steve Karp, M.S.,
at [email protected] or (707) 826-4190.
For specific questions about this study, you may contact the program’s principal investigator, Connie
Stewart, California Center for Rural Policy, HSU at 707-826-3402.
Approval Date
This form was approved in July 2016 for use for one year.
Statement of Informed Consent
I have read and understood what it means to be a part of this project. I was given the opportunity to
contact the evaluator to ask questions. By signing this informed consent form, I indicate that would like
to be a part of this project. I have been given a copy of this consent form.
___________________________
Printed Name of Participant
________________________________
Signed Name of Participant
_________________________ ________________________________
Printed Name of Investigator
Signed Name of Evaluator
_________
Date
_________
Date
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