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Registration
Admin
2025-05-30T15:12:55-07:00
Participant Registration
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Participant Enrollment
(Required)
I am an ADULT (18+ Years Old), enrolling only MYSELF to participate in ECLD programming
I am a PARENT/GUARDIAN, enrolling MYSELF and my YOUTH to participate in ECLD programming
Adult Contact Information
Your Name
(Required)
First
Last
Your Address
(Required)
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date of Birth
(Required)
MM slash DD slash YYYY
Your Phone
(Required)
Tribal Lineage
(Required)
Fernandeño Tataviam Band of Mission Indians
Santa Ynez Band of Chumash Indians
Gabrielino/Tongva Nation
Cherokee Nation
Choctaw Nation of Oklahoma
Comanche Nation
Huichol
Mazahua
Other Tribal Lineage
No Tribal Lineage/Heritage
Race and Ethnicity
(Required)
White/Caucasian
Black/African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern/North African
Other
Other Tribal Lineage
(Required)
Add
Remove
Please list the name of your Tribal Lineage that was not listed in the previous question
Create Log in Credentials
Username
Your Email Address
(Required)
Email Address
Confirm Email Address
Password
Enter Password
Confirm Password
Participation Agreement
Participation Agreement
(Required)
I acknowledge and agree to have read and understood the Participation Agreement and Release.
Participation Agreement and Release
This Participation Agreement and Release (“Agreement”) is entered into by and between the Fernandeño Tataviam Band of Mission Indians (FTBMI) Education & Cultural Learning Department and its agents (collectively referred to as “ECLD”) and the undersigned Participant, or the legal guardian of the Participant if under 18 years of age, as of the date signed below.
In consideration of the opportunity to participate in ECLD programs and activities, and for other valuable consideration, the undersigned agrees to the following terms:
1. Code of Conduct
The Participant understands and agrees that:
- The use of illegal drugs, alcohol, smoking tobacco, and weapons is strictly prohibited at all ECLD program locations and the Administration Office.
- Prescription medications may only be used as directed by a licensed physician.
- Tobacco may only be used in culturally appropriate ways. Ceremonial use (e.g., burning or smoking tobacco) is permitted only with prior approval from FTBMI and advance notice to ECLD management.
2. No Warranties
ECLD makes no warranties—express, implied, or statutory—regarding the safety, quality, or outcomes of any program, activity, or facility used.
3. Release of Claims
The undersigned voluntarily and irrevocably releases and discharges ECLD, its officers, staff, volunteers, funders, partners, and sponsors from any and all claims, liabilities, or damages arising from:
- Participation in ECLD programs or activities;
- Transportation provided by ECLD or third parties;
- Use of the Participant’s image, voice, or biographical information in media or promotional materials;
- Any distortion, alteration, or composite use of such materials.
4. Waiver of Unknown Claims
The undersigned waives all rights under Section 1542 of the California Civil Code, which states:
“A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor.”
This means the Participant gives up the right to bring claims in the future, even if they were unknown at the time of signing.
5. Limitation of Liability
ECLD’s total liability for any claim related to this Agreement or participation in its programs is limited to fifty dollars ($50). ECLD is not liable for any indirect, incidental, or consequential damages, including lost profits.
6. Governing Law
This Agreement is governed by the laws of the Fernandeño Tataviam Band of Mission Indians and the State of California, without regard to conflict of law principles.
7. Acknowledgment
By signing below, the undersigned confirms they have read, understood, and agreed to the terms of this Agreement on behalf of themselves or the minor Participant.
Participation Agreement: Adult Name
(Required)
First
Last
Participation Agreement: Signature
(Required)
Would you like to participate in a brief data collection survey that will influence our program planning?
(Required)
Yes, I would like to participate in the brief data collection survey that will be used to influence programming
No, I would NOT like to participate in the brief data collection survey that will be used to influence programming
What types of programs or teachings are you seeking to participate in by enrolling in our department?
(Required)
Cultural Workshops
Traditional Ceremonies
Academic Support
College and Career Support
Outdoor Recreation and Adventures
Community Building/Community Service
Leadership Development/Mentorships
Traditional Knowledge/Traditional Plants/Medicine
History and Native Identity
Peer to Peer Connection
Youth-Led Advocacy/Systematic Change
Youth #1 Information
Youth under 18 years old can be enrolled in this section.
Youth #1 Name
(Required)
First
Last
Preferred Name
Youth #1: Date of Birth
(Required)
MM slash DD slash YYYY
Youth #1 Home Address
(Required)
Youth's Home Address is the SAME as Parent/Guardian enrolled on this form
Youth's Home Address is DIFFERENT as the Parent/Guardian enrolled on this form
Home Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please select Youth's Grade Range
(Required)
Grades K-12
Infant/Nursery/T-K/Pre-K/Preschool
Which grade range does your youth fall within?
Current Grade Level
(Required)
T-K/Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Grade Level for (Summer/Fall-Spring)
Name of School or Home School Program
(Required)
School Address
(Required)
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Are your youth on Free or Reduced Lunch?
(Required)
Yes, my youth are on free or reduced lunch
No, my youth are NOT on free or reduces lunch
Not Applicable (Not enrolled in school/home school program)
Is transportation to San Fernando accessible to your youth?
(Required)
Yes, transportation to San Fernando is accessible to my youth
No, transportation to San Fernando is NOT accessible to my youth
Race and Ethnicity
(Required)
White/Caucasian
Black/African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern/North African
Other
Youth Tribal Lineage
(Required)
Fernandeño Tataviam Band of Mission Indians
Santa Ynez Band of Chumash Indians
Gabrielino/Tongva Nation
Cherokee Nation
Choctaw Nation of Oklahoma
Comanche Nation
Huichol
Mazahua
Other Tribal Lineage
Unknown Tribal Heritage/Lineage
Other Tribal Lineage
(Required)
Please list the name of your Tribal Lineage that was not listed in the previous question
Youth's Emergency Contact List
ECLD has permission to release the listed youth into the care of the Adults listed in this section.
Emergency Contact #1
(Required)
First
Last
Relationship to Youth
(Required)
Contact's Phone Number
(Required)
Emergency Contact #2
(Required)
First
Last
Relationship to Youth
(Required)
Contact's Phone Number
(Required)
Emergency Contact #3
(Required)
First
Last
Relationship to Youth
(Required)
Contact's Phone Number
(Required)
Would you like to enroll another youth?
(Required)
Yes, I would like to enroll another youth
No, I would NOT like to enroll another youth
Youth #2 Information
Youth #2 Name
(Required)
First
Last
Preferred Name
Youth #2: Date of Birth
(Required)
MM slash DD slash YYYY
Youth #2 Home Address
(Required)
Youth's Home Address is the SAME as Parent/Guardian enrolled on this form
Youth's Home Address is DIFFERENT as the Parent/Guardian enrolled on this form
Home Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Current Grade Level (Youth #2)
(Required)
T-K/Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Grade Level for (Summer/Fall-Spring)
Please select Youth's Grade Range
(Required)
Grades K-12
Infant/Nursery/T-K/Pre-K/Preschool
Which grade range does your youth fall within?
Name of School or Home School Program
(Required)
School Address
(Required)
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Youth Tribal Lineage
(Required)
Fernandeño Tataviam Band of Mission Indians
Santa Ynez Band of Chumash Indians
Gabrielino/Tongva Nation
Cherokee Nation
Choctaw Nation of Oklahoma
Comanche Nation
Huichol
Mazahua
Other Tribal Lineage
Unknown Tribal Heritage/Lineage
Race and Ethnicity
(Required)
White/Caucasian
Black/African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern/North African
Other
Other Tribal Lineage
(Required)
Please list the name of your Tribal Lineage that was not listed in the previous question
Email
This field is for validation purposes and should be left unchanged.
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