Native American Fish and Wildlife Sciety 8515 Pearl Street Suite 203 Thrntn, Clrad 80229 Phne: 303.466.1725 Fax: 303.466.5414 www.nafws.rg 21 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 505/259-4189 (cell phne); r Nrman Jjla at: (ffice) 505/753-1451 r (cell phne) 505/927-3494. All Applicatins Must Be Received r Pstmarked By May 25, 2018. Selectins will be made by June 4, 2018 and students will be ntified by June 6, 2018. Only COMPLETE APPLICATIONS will be accepted. Please send cmpleted applicatins t: Jeanne Lubbering, 59 Santa Maria Dr., Edgewd, NM, 87015 r Nrman Jjla, P. O. Bx 1451, Espanla, NM 87532, r Fax 505/753-1486. Celebrating 36 years f serving tribes
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, 2018. PLEASE SEND COMPLETED APPLICATIONS TO: JEANNE LUBBERING r NORMAN JOJOLA 59 SANTA MARIA DR. P. O. BOX 1451 EDGEWOOD, NM 87015 ESPANOLA, NM 87532 PHONE: 505/259-4189 PHONE: (ffice) 505/753-1451 (cell phne) 505/927-3494 FAX: 505/753-1486
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): E-mail 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?
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:
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:
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: