Native American Fish and Wildlife Society

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1 Native American Fish and Wildlife Sciety 8515 Pearl Street Suite 203 Thrntn, Clrad Phne: Fax: st ANNUAL NATIVE AMERICAN NATURAL RESOURCES YOUTH PRACTICUM Spnsred By Native American Fish & Wildlife Sciety Suthwest Regin When: June 18-22, 2018 Where: Open T: Ri Mra Natinal Wildlife Refuge, Waltrus, New Mexic Incming 10th, 11th, & 12th Grade Students The Practicum is pen t all Native American high schl students frm Arizna, Clrad, Nevada, New Mexic, suthern Califrnia, and Utah wh have an interest in pursuing a career in fishery and wildlife management, frestry, range management, watershed management, hydrlgy, r ther natural resurces related field. The Practicum prvides a "hands-n" learning experience in natural resurce management and cmbines classrm with field sessins that enables students t learn cncepts and techniques used t manage natural resurces. The Practicum is prvided by the Suthwest Regin, Native American Fish and Wildlife Sciety at ncst t the participating students. Summer temperatures in the area during June/July range frm the 50's t 80 degrees Fahrenheit. Sme strenuus hiking will be invlved. Fr mre infrmatin, cntact Jeanne Lubbering at 505/ (cell phne); r Nrman Jjla at: (ffice) 505/ r (cell phne) 505/ All Applicatins Must Be Received r Pstmarked By May 25, Selectins will be made by June 4, 2018 and students will be ntified by June 6, Only COMPLETE APPLICATIONS will be accepted. Please send cmpleted applicatins t: Jeanne Lubbering, 59 Santa Maria Dr., Edgewd, NM, r Nrman Jjla, P. O. Bx 1451, Espanla, NM 87532, r Fax 505/ Celebrating 36 years f serving tribes

2 Page 2 Suthwest Regin Native American Fish & Wildlife Sciety 2018 Natural Resurces Yuth Practicum CHECKLIST Make sure yu have cmpleted and enclsed the fllwing materials: Applicatin Frm Essay Signed Student/Parent Cntract, Signed Picture Release Statement (Same Page) Student Emergency Medical Infrmatin Frm ALL APPLICATIONS MUST BE RECEIVED BY May 25, PLEASE SEND COMPLETED APPLICATIONS TO: JEANNE LUBBERING r NORMAN JOJOLA 59 SANTA MARIA DR. P. O. BOX 1451 EDGEWOOD, NM ESPANOLA, NM PHONE: 505/ PHONE: (ffice) 505/ (cell phne) 505/ FAX: 505/

3 Page 3 NAFWS-SW Regin 2018 Natural Resurces Yuth Practicum Applicatin /Admissin Frm Name: Address: City: State: Zip Cde: Phne: Birthdate/Age: Schl: Grade (Fall 2018): Tribal Affiliatin: Enrllment #: Name f Parent(s) r Guardian(s): Phne Number f Parent(s) r Guardian(s): Address: Emergency Cntact Infrmatin: (Fr Emergency Purpses Only) Name f Next f Kin: Relatinship: Phne Number f Next f Kin: Special Fd/Dietary Restrictins: T- Shirt Size - Sm Med Lg XLg XXLg ON A SEPARATE SHEET OF PAPER, PLEASE PREPARE A SHORT ESSAY WHICH INCLUDES: Yur interests and activities in Natural Resurces such as fisheries, wildlife, frestry, and range management. What is Natural Resurces Management and Cnservatin? What area f Natural Resurces Management and Cnservatin wuld yu like t learn mre abut and why? What area f Natural Resurces Management and Cnservatin d yu feel is mst imprtant t ur future and why? What kind f Natural Resurces Management and Cnservatin is being dne n yur Reservatin? What wuld yu d t imprve it?

4 Page 4 EMERGENCY MEDICAL INFORMATION 2018 PRACTICUM (T be filled ut by Parent r Guardian) Student Name: Phne: Address: City: State: Zip: Parent/Guardian: Wrk Phne: Relatinship t Student: Physician s Name: Physician s Address: Physician s Phne Number: Medical Insurance Cmpany: Plicy Number: Is yur child eligible fr Indian Health Service cntract health care? Indian Health Service Unit Address: Indian Health Service Unit Phne Number: Des yur child have any physical disabilities? (explain) Des yur child have severe nsebleeds r ther physical cnditins that require precautins r special treatment? (explain) Des yur child wear glasses r cntact lenses? Des yur child have Hay Fever? Sinus Prblems? If yur child has Hay Fever r Sinus Prblems, are they n medicatin? If yes, what kind f medicatin? Is yur child allergic t Insect bites r stings? Please explain situatin with allergies: Has yur child had any majr illnesses within the past 5 years? If s, please explain:

5 Page 5 EMERGENCY MEDICAL INFORMATION 2018 PRACTICUM (Cntinued) Is yur child currently taking any medicatin? If yes, what kind? Des yur child require assistance t take medicatin? Is yur child allergic t any kind f medicatins? If yes, what are these medicatins? IF YOUR CHILD REQUIRES ANY TYPE OF MEDICATION, PLEASE ENSURE THEY HAVE AN ADEQUATE SUPPLY Please prvide any ther infrmatin yu feel is imprtant:

6 Page 6 NAFWS SW Regin 2018 Natural Resurces Yuth Practicum Student/Parent Cntract Acceptance t the 2018 Natural Resurces Yuth Practicum is a privilege and it als requires Students and Parents t assume certain respnsibilities. STUDENT: I, stipulated belw:, as part f the 2018 Natural Resurces Yuth Practicum, accept the cnditins 1. I will participate in and be n time t all sessins and activities, unless excused by a staff member. 2. I will cnduct myself in an rderly manner at all times and will be respectful and curteus t everyne. 3. I will sleep where assigned and realize that I will be with peple I have never met befre. 4. I understand that at bedtime, all lights must be ut when requested and that there will be a bed check every night. 5. I understand that drugs, alchl, r any tbacc prducts are NOT allwed during the Practicum and I als understand that if I am caught using drugs, alchl, r any tbacc prducts, I will immediately be sent hme AT MY PARENTS' EXPENSE. 6. I understand that I will be held respnsible fr any damage that I have caused t Practicum equipment r t the Ri Mra Natinal Wildlife Refuge facilities. 7. I understand that I will adhere t the established quiet time hurs and the bed time lights-ut hurs established by the Practicum staff. 8. I understand that n water ballns r squirt-guns will be allwed. 9. I understand that NO Prtable Music Devices and Cell Phnes will be allwed. LEAVE THEM HOME OR THEY BECOME THE PROPERTY OF THE PRACTICUM. 10. I understand that NO Gang-related r Heavy Metal-related Clthing Will Be Allwed. ALL PANTS WILL BE WORN AT THE WAISTLINE. 11. I will adhere t all rules f the NAFWS Natural Resurces Yuth Practicum and the Ri Mra Natinal Wildlife Refuge. Signature f Student: Date: PARENT/GUARDIAN: I have read, understand and agree with the abve terms. Permissin is given fr my child t participate in all activities and events, and fr my child t receive all necessary medical attentin shuld the need arise, with the understanding that I will be cntacted immediately. Furthermre: 1. I understand that the Native American Fish & Wildlife Sciety r their staff will nt be respnsible fr any theft, injury, r illness where my child is cncerned. 2. I give permissin fr any staff member t render first aid t my child if necessary. 3. I give my cnsent and permissin fr hspital staff t treat my child in the case f emergency, with the understanding that I will be cntacted immediately. 4. I understand that my child will be chaperned respnsibly and every effrt will be made t ensure a safe and enjyable experience. 5. I understand that n drugs, alchl, r tbacc prducts are permitted and that if my child is caught with any f these substances, they will immediately be dismissed and I will be ntified t immediately pick them up AT MY OWN EXPENSE. 6. I understand that as part f my child's applicatin, the STUDENT EMERGENCY INFORMATION FORM IS REQUIRED TO BE COMPLETED AND ON FILE. Signature f Parent/Guardian: Date: PICTURE RELEASE STATEMENT: I give permissin fr my picture t be taken in cnjunctin with the 2018 Suthwest Native American Fish & Wildlife Sciety Natural Resurces Yuth Practicum and t be used in newspapers, magazines, vides and ther media cncerning the Practicum withut mnetary cmpensatin. Signature f Student: Date: Signature f Parent/Guardian: Date:

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