FY25 Revisions Youth Education

Youth Education

General Application for Services
Session ID
Student Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Student Phone
If you are 18 or older. Please enter a valid phone number.
School *
Last Grade Attended*
School Student ID Number
The following information is necessary for various funding and reporting obligations.
Student Gender*
Student Education Level*
Are you a veteran?

YesNo
Proof of Tribal Affiliation

Cook Inlet Tribal Council, Youth Empowerment Services programs are grant funded and may require that you show proof of Alaska Native/American Indian heritage or Tribal Affiliation for your student. Please click the upload button above to attached documents.
Cancelof

Educational Goals
What is your purpose in applying for participation in the Youth Empowerment Services program(s)?
Examples: Afterschool activities, Camps, Academic Support, Cultural Enrichment, etc
Why is this important to you and how will it relate to your educational goals?
Examples: Improve academics, Increase self-awareness, Improve confidence in educational settings, Increase GPA / graduation assistance, etc

Medical Information
Do you have a preferred doctor?

YesNo
Physician Name

First NameLast Name
Physician Phone
Please enter a valid phone number.
Do you have a preferred hospital?

YesNo
Hospital Name
Health or Physical Conditions*
None
Does your child require prescription or over the counter medication during program hours?
If your child has medication needs (prescription or over the counter) please email yesdept@citci.org.
Allergies*

NoneMild AllergiesSevere Allergies
Allergy Details
Are there any other medical or behavioral concerns?*
None

Parent / Legal Guardian Information
Primary
First Name*
Last Name*
Relationship to Student*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone*
Please enter a valid phone number.
2nd Phone
Please enter a valid phone number.
Guardian Email*
example@example.com
Is there a 2nd Parent / Legal Guardian?

YesNo
Secondary
First Name
Last Name
Same Address?

YesNo
Secondary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone
Please enter a valid phone number.
2nd Phone
Please enter a valid phone number.
Guardian Email
example@example.com

Emergency Contact
Please provide an emergency contact that is not already a parent / legal guardian.
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.
Authorized to pick-up?*

YesNo
Authorized Pick-Up
Student Check-Out: (Please indicate how your student will go home at the end of the day.)*

Authorized or Parent Pick-UpCity BusSelf TransportationWalk Home
Please identify any people that are authorized to pick up your child (i.e. grand parent, neighbor, siblings, etc...)
Name #1
Phone Number #1
Please enter a valid phone number.
Name #2
Phone Number #2
Please enter a valid phone number.
I authorize CITC personnel to transport my student in CITC vehicles. I also authorize my student to be transported by other organizations approved by CITC.*

YesNo
Signature*

Clear

CITC use images and video to promote and share programs. Do you consent to CITC using images and video with your child in it?
Media Release

FOR COOK INLET TRIBAL COUNCIL, INC., ALASKA NATIVE JUSTICE CENTER, INC., CLARE SWAN EARLY LEARNING CENTER AND/OR GET OUT THE NATIVE VOTE
I grant Cook Inlet Tribal Council, Inc., Alaska Native Justice Center, Inc. (ANJC), Clare Swan Early Learning Center (CSELC), and/or Get Out the Native Vote (GOTNV), and their agents, affiliates, and assigns (collectively "CITC") permission to use my and/or my child[ren]'s likeness in images captured for use in photograph, print, film, or other digital reproduction in any and all of its publications and any media, including social media (collectively "Media"), and I fully understand and acknowledge that:
- my and my child(ren)'s participation in CITC's Media activity is strictly voluntary;
- I or my child[ren] may be photographed and/or videotaped for educational, promotional, commercial, and archival purposes. I grant CITC permission to use my and/or my child[ren]'s likeness in images captured for Media use;
- I irrevocably authorize CITC to edit, alter, copy, exhibit, publish, or distribute images of me or my child[ren)'s likeness in any Media for purposes of publicizing CITC's programs or for any other lawful purpose, including but not limited to commercial and informational and training purposes, video games, film, books, posters, cultural and language materials, and other forms of content without payment or any other consideration;
- my and/or my child[ren)'s or dependent's confidentiality as a CITC participant, if applicable, may be waived when CITC use an image in Media, and I voluntarily consent to their use, understanding that these uses may be subject to public use and/or view without my knowledge or previous consent and will not be returned; and
- I waive the right to inspect or approve the finished product, including written or electronic copy, where my or my child[ren]'s likeness appears. I also waive any right to royalties or other compensation arising from or related to the use of my or my child[ren]'s image(s) in any form and for any purpose. I hold CITC harmless and release and forever discharge CITC, its directors, officers, employees, agents and assigns from all claims, demands, and causes of action which I, and/or my child[ren]'s heirs, representatives, executors, administrators, or any other persons acting on my and/or my child[ren]'s behalf or on behalf of my and/or my child[ren)'s estate have or may have related to my or my child[ren]'s likeness or any CITC publication or media of any type.
By signing below, I confirm that I am at least eighteen (18) years old and am competent to contract in my own name. I have read this release before signing. I fully understand the contents, meaning, and impact of this Media Release.
Student Name*

First NameLast Name
Parent / Guardian / Adult Student Signature*

Clear

Youth Code of Conduct
This is to affirm that I agree to the following terms and conditions for participation in the CITC Youth Empowerment Services Program:
- I understand any technology I bring other than a laptop for schoolwork, will be placed in a designated technology area.
- I will let staff know if I need to use my phone before retrieving it from the technology area.
- I will abide by the rules of CITC Youth Empowerment Services Program and follow the instructions given by the instructors, counselors, staff, and supervisors.
- I will respect the culture and ways of others and be respectful of their words and thoughts.
- I will participate in the scheduled activities, to the best of my abilities.
- I will be accountable for my whereabouts at all times, agreeing to keep staff informed of my plans and activities.
- I will keep my hands and extensions to myself, which means I will not engage in public displays of affection or aggression.
- I will refrain from any behavior deemed inappropriate or behavior that involves risk to others, or myself (e.g., inappropriate use of CITC equipment, leaving CITC Youth Empowerment Service Program without permission).
- I will give CITC equipment and facilities the highest levels of care and consideration. If I misuse equipment or materials, I may not be allowed to use them.
- If I cause any danger, damage, or disruption in any manner to the Youth Empowerment Services Programs’ employees, visitors, participants, grounds, facilities, and/or other programs, I fully understand that I will be subject to disciplinary actions to and including expulsion from Youth Empowerment Services Programs and may be prohibited from returning to CITC’s property.
Dress Code:

Shirts:
- Should not be revealing (no spaghetti straps).
- Should be long enough that the midriff does not show.
- Should not display messages that are disruptive to the learning environment.
- This includes inappropriate language/images, and should not promote alcohol or drugs.
Skirts/Pants/Shorts:
- Skirts and shorts should be no higher than 2 inches above the knee when measured from a kneeling position.
- The waistline of the pants may not sag below the waist of the wearer
Leggings:
- Leggings & athleisure may be worn, but cannot be see through.
  Shoes:
- Students should wear functional shoes at all times for safety (preferably sneakers). If activity occurs in Fab Lab, closed toes shoes are required.
Weather:
- Students are responsible to dress appropriately for the weather.
I agree and consent to my child[ren]’s participation in any program with in Youth Empowerment Services and assume the CITC YES Department Staff is dedicated to provide a safe space for our students while understanding that no measures can be completely eradicate the risks and hazards of all activates. By enrolling a student(s) at CITC YES Department, families understand and accept the risk of injury, which may occur.
I acknowledge I have read and understand the Youth Code of Conduct. I agree to its terms and conditions and confirm that I have discussed the Youth Code of Conduct with my child(ren).*

Yes
Student Name*

First NameLast Name
Parent / Guardian / Adult Student Signature*

Clear

Mental Health Counseling

CITC recognizes the value of having someone to talk to in a safe, convenient, and private setting - especially for our youth. CITC offers mental health counselling to Youth Participants, as an optional service.
Do you consent to participating in this service with CITC? (Select Yes to review and sign the informed consent)*
CITC Youth Participant Informed Consent to Treat

This informed Consent Form provides information about these services and asks you for your permission to provide these services to your child:

By signing this form, you are indicating that you understand and agree to the following statements:

Informed Consent: As the parent or legal guardian of a minor Participant, I have the right to make informed decisions about my child’s care. I have been given a statement of my Participant Rights and Responsibilities. I understand my informed consent rights include being informed of my child’s health status, being involved in care planning and treatment, and being able to request or refuse treatment. I understand, if it is my wish to do so, I may delegate my right to make informed decisions to another person. To the degree permitted by state law, and to the maximum extent practicable, CITC must respect my wishes and follow that process.

Assessment, Treatment, and Activities: My child may receive a variety of services, with the most common being individual and small group counselling to help understand and overcome emotional, social, and behavioral challenges or in coping with a crisis, such as the as a death or other traumatic event. In some situations, a child may have more significant mental health care needs. In this case, a CITC provider will discuss with you the nature of the symptoms and conditions, proposed treatments, benefits and risks associated with treatment, probability of successful outcomes, and any treatment alternatives. CITC may also help me to find another provider that I am comfortable with to provide needed or beneficial services. I understand I may revoke consent to further care at any time by letting my CITC provider know.

Confidentiality: I have been provided a copy of CITC’s Notice of Privacy Practices, which is also available online: https://citci.org or upon request. CITC adheres to state and federal confidentiality laws, including Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Receiving or sharing personal information about my child with any other party requires my written consent, except for those disclosures required or permitted by law.

Insurance Authorization: CITC will not seek payment from me for any costs. However, CITC may seek payment from my insurance carrier for some services. I agree to update my insurance on file with CITC and to inform CITC of any changes in coverage. CITC will make reasonable efforts to confirm insurance, obtain prior authorizations, and obtain referrals as may be required by my insurance carrier. If I am a Medicare or Medicaid patient, I will provide to CITC, or ensure my referring provider has provided, both my Medicare/Medicaid ID card and, if applicable, my secondary insurance ID card. If I am eligible for these benefits, CITC can help me to enroll in these programs.

Assignment of Benefits. By accepting treatment from CITC, I authorize the release of any PHI or other information regarding my treatment to any insurance carrier or other applicable third-party payor or financially responsible entity or individual for the purpose of securing payments for services rendered to me, and assign and set over to CITC any benefits for the cost of treatment that I may be entitled to as a result. I further authorize the third-party payor to make payment directly to CITC. This assignment includes all rights to collect benefits directly from my insurance company and all rights to proceed against my insurance company in any action, including legal suit, if for any reason my insurance company fails to make payment of benefits due. This assignment also includes all rights to recover attorney’s fees and costs for such action brought by the provider as my assignee.

I UNDERSTAND I HAVE THE RIGHT TO REVOKE CONSENT TO FURTHER USE OR DISCLOSURES AT ANY TIME BY INFORMING A CITC REPRESENTATIVE OF MY DESIRE TO DO SO. HOWEVER, SUCH REVOCATION SHALL NOT AFFECT ANY TREATMENT, SERVICES, DISCLOSURES OR OBLIGATIONS ALREADY MADE IN COMPLIANCE WITH MY PRIOR CONSENT TO TREATMENT. CITC PROVIDES THIS NOTICE TO ITS PARTICIPANTS IN ORDER TO COMPLY WITH HIPAA, THE CENTERS FOR MEDICARE & MEDICAID SERVICES, AND ANY APPLICABLE STATE AND FEDERAL LAWS.

By my signature, I understand and agree that I have read and understood this Agreement. I also attest that I am the parent or legal guardian of the child and have not had my ability to provide consent to healthcare revoked or modified.
Parent / Guardian First Name*
Parent / Guardian Last Name*
Parent Guardian Signature*

Clear

CITC collects student information to assist with grants and program impact assessments. This information also helps keep the YES program funded. Do you consent to sharing this information with CITC?
Consent for Release of Education Records

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF EDUCATION RECORDS
The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records created or maintained by a school that receives federal funds. Completion of this document authorizes the disclosure and use of education records as described below. Completion also authorizes you to discuss this information with representatives of the organization named below entitled to receive said information.
Student Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Student Identification
Current Grade*
School *
Use and Disclosure Information:
I, the undersigned, do hereby authorize to disclose and deliver the complete education records maintained under the above student's name.
I approval the sharing of the following educational records:*

Grades and TranscriptsEducational TestingGraduationAttendance
The educational records can be shared with:

Name: Youth Empowerment Services
Organization: Cook Inlet Tribal Council
Address: 3600 San Jeronimo Dr Anchorage, Alaska 99508

Purpose:

This information is to disclosed for the purpose of:
- Sharing of Educational Records
- Grants Reporting
- Longitudinal Data
- Program impact assessment
Authorization for Redisclosure:

Under federal law, the requester (Cook Inlet tribal Council) may not redisclose the information identified above to any other party without your consent. If you wish to authorize Cook Inlet Tribal Council to redisclose the information identified above please mark the box below:
I authorize the Cook Inlet Tribal Council to redisclose the education information described above and I understand that if the information is redisclosed it may not be protected by federal privileges, privacy laws or regulations.*

YesNo
Parent / Guardian First Name*
Parent / Guardian Last Name*
Relationship to Student*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Youth Education

Student Information

Educational Goals

Medical Information

Parent / Legal Guardian Information

Primary

Secondary

Emergency Contact

Authorized Pick-Up

Media Release

Youth Code of Conduct

Dress Code:

Mental Health Counseling

CITC Youth Participant Informed Consent to Treat

Consent for Release of Education Records

Student Information

Use and Disclosure Information: