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Traditional Teachings Summer Camp Application

Complete the camp registration and information application below for each camper attending.

If you have any questions, please contact:

Arianna Chavez – Cultural Education Director at 505-212-7060 Email: Achavez@indianpueblo.org
Or Alejandra Cortes, Education Specialist at 505-212-7032 Email: acortes@indianpueblo.org

Early bird enrollment: March 1st - 31st, Price : $180
Open enrollment: April 1st - 23rd, Price: $200
Late bird enrollment: April 24th - May 15th, Price: $220

Scholarships are available. Deadline to apply for a scholarship is April 21st.

* Indicates required field

Step 1 of 6

16%

Application Information
Select Which Camp You Are Registering For*
- 6-9 Year Olds June 26th-30th, 2023
- 10-13 Year Olds, July 10th-14th, 2023
Participant Information:
Name*
First Last
Pronunciation of Name (optional):
Nickname / Preferred Name (optional):
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Parent/Guardian Email*
Enter Email Confirm Email
Name of Parent/Guardian*
First Last
Relationship to Child*
T-shirt Size*
- Youth Small
- Youth Medium
- Youth Large
- Youth Extra Large
- Adult Small
- Adult Medium
- Adult Large
- Adult Extra Large

Emergency Contacts
In the event of an emergency, contact the following
Primary Contact Name*
First Last
Primary Contact Relationship to Child*
Primary Contact Phone*
Secondary Contact Name*
First Last
Secondary Contact Relationship to Child*
Secondary Contact Phone*

Medical Authorization Section 1: Authorization to Permit Medical Treatment
By Signing below, I authorize the Indian Pueblo Cultural Center, Indian Pueblos Marketing, Inc., its employees, volunteers, or interns (collectively referred to as “the IPCC”) to seek medical assistance on behalf of my child in the event I am unavailable to indicate my wishes, regarding treatment. I understand that the IPCC shall not be held responsible for the costs of treatment. I hereby grant permission to emergency personnel, physicians and other licensed health care providers and their designees to attend, transport, and administer medical care through injury or illness evaluation, first aide care and referral to duty licensed medical personnel when indicated. I waive release and discharge the IPCC from any and all claims, liability and damages arising from the provision of such medical treatment.
Name of Child*
First Last
Age*
Date of Birth*
MM slash DD slash YYYY
Gender*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone Number*
Cell Number*
Parent/Guardian Email*
Parent/Legal Guardian’s Signature Signature*

By typing your full name here you are signing to permit medical treatment.
Date
MM slash DD slash YYYY

Medical Authorization Form Section 2: Release of Information
I authorize the release of the medical information below to emergency personnel and treatment providers, and will not hold the IPCC in any way responsible for the release of this information to any emergency personnel or treatment provider.
Name*
First Last
Medical Insurer/Health Plan*
Policy #*
Physician's Name
First Last
Physician’s Phone
Consent*
I authorize to release information
Parent/Legal Guardian’s Signature Signature*

By typing your full name here you are signing to permit medical treatment.
Date
MM slash DD slash YYYY

Medical History
Medications*
If the participant takes any medications, please list medication name and dosage. Instructors cannot dispense prescription medicines. If the participant must take a medication during the program, she/he must be able to take personal responsibility for the medications.
Allergies/Allergic Reactions (Select all that apply)*
- Animals
- Food
- Bee Stings
- Insect Stings
- Other
(Specify reaction and management of the reaction.) If participant has a known anaphylactic reaction, she/he must carry an EpiPen and an antihistamine at all times while outdoors. Select which Allergen(s) apply to your child
Specify Allergen Reaction
If you selected any allergens in the previous question, specify allergen reaction (i.e. animal, food, insect, etc.)
Health Conditions*
Additional Comments/Notes
Please provide any additional information that may be useful to the IPCC in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted.

Photo Consent*
Do you, (parent/legal guardian) hereby grant permission to the Indian Pueblo Cultural Center to take photos and video of my child while he/she is enrolled in the Indian Pueblo Cultural Centers Traditional Teachings Camp. I further understand and acknowledge that any photograph or video taken by Indian Pueblo Cultural Center staff members may be used in the Indian Pueblo Cultural Center’s newsletter, website, flyers, brochures, or fundraising efforts. The Indian Pueblo Cultural Center may share photographs and videos with participants; however, original negatives and video will remain the property of the Indian Pueblo Cultural Center?
- Yes, I consent.
- No, I do not consent.
Parent/Legal Guardian’s Signature
First Last
By entering your name here you are signing to give photo consent.
Date
MM slash DD slash YYYY
Release of Liability
Consent*
I, the parent/legal guardian do hereby solemnly affirm custody of the participant. As the parent or legal guardian of the child registering for camp in this form I allow him/her to participate in the Indian Cultural Center 2023 Traditional Teachings Camps. I have carefully read the policies for this camp and understand that there may be certain risks involved. I agree to follow all policies and procedures. I also agree that I will instruct the participant to follow all instructions by him/her program leaders, volunteers and interns and I assume all liability for the participants failure to follow instructions.

I understand that the program instructors may immediately withdraw the participant from the program if he/she is unable or unwilling to follow instructions. In consideration of the participant volunteering in the program (garden project), I waive, release, and discharge the Indian Pueblo Cultural Center, Indian Pueblos Marketing, Inc. and its employees, agents, representatives, and volunteers, from any and all claims, liability, and damages resulting directly or indirectly from the participants taking part in the program including but not limited to those: 1) arising from personal injury and/or property damage suffered by the participant, whether resulting from negligence or other conduct, including all acts and omissions, of the IPCC, its employees, agents, or volunteers, the conduct of another participant, the conduct of a non-participant, or from any other cause; 2) arising from the release or use of medical information by the IPCC for the purpose of providing medical treatment to the participant; and 3) arising from the provision of such medical treatment.

I have carefully read this authorization and I acknowledge that I fully understand its contents and agree for myself and my child to be bound by all terms and conditions set forth therein. My signature is evidence of my understanding and commitment to this authorization.

I consent to release of liability
Signature
First Last
By entering my name here I signing to give consent and agree.
Email
This field is for validation purposes and should be left unchanged.

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Indian Pueblo Cultural Center
2401 12th Street NW
Albuquerque, New Mexico 87104
Phone: Local: 505-843-7270 Toll Free: 1-866-855-7902

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8

Total Number of Years of classroom teaching experience

What grade levels have you taught?

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6

7

8

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Phone(Required)

Email(Required)

Have you served as a Curriculum Writer for IPCC in the past?(Required)

Yes

No

If Yes, what subject areas and for what grade levels?

Tell us about your overall teaching experience:

Current School

Years

Most Recent Grades you have taught

K

1

2

3

4

5

Total Number of Years of classroom teaching experience

What grade levels have you taught?

Select all that apply.

K

1

2

3

4

5

How many years of curriculum development experience do you have in the following content areas?

Science

Language Arts

Social Studies

Mathematics

Briefly describe your experience in developing curriculum for elementary grades:

Briefly describe how you incorporated NM State Standards or Common Core into your daily lesson plans:

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