Youth Development Program Registration


Parent/Guardian: This form serves as an application into the Future Inspired Native American Leaders College and Career Readiness program. An orientation into the program is required for all participants and must be attended by both parent/guardian and student. This form must be completed by a parent or legal guardian of the student listed below.


Student Name:*
Date of Birth:*
Tribal Affiliation:*
Grade (2019-2020 School Year):*
Graduation Year:*
High School:*
School District:*
Student Phone:
Student E-mail:
Physical Address:*


Parent/ Guardian Name:*
Parent E-mail:*
Relationship to Student:*
Parent Phone:*
Work Phone:*


Emergency Contact Name:*
Relationship to the Student:*
Emergency Contact Phone:*


Food Allergies:
Other Allergies (Medication/ Seasonal/Insect):
Special Health Conditions:


What activities are you involved with?
Indicate if you are in any early college programs:
Indicate if you are interested in other Phoenix Indian Center programming:


Enrollment for Future Inspired Native American Leaders program is on-going throughout the year. Orientations are scheduled throughout the year when new students apply with exception to the months of June and July. These months are designated for an overview of the Summer Academy event and will require admission to Phoenix College for classes. Participation in the Summer Academy requires a mandatory orientation for both Student and Parent/Guardian. Failure to attend one of the four orientations will prevent the student from participating in the Summer Academy but may continue in the program during the Fall 2019. Classes for Summer Academy will be taught by instructors at Phoenix College and students will enroll during the June or July orientation. Students will not be accepted into the Summer Academy if they have not attended one of the orientations with their Parent/Guardian and have not submitted all supporting documents by the final orientation date (July 8, 2019).


  • Student Photo ID (Current School ID, Arizona Identification Card, Arizona Driver’s License, US Passport, or Tribal ID)
  • Lawful Presence (Birth Certificate, US Passport, Certificate of Indian Blood, or Arizona Driver’s License)
  • Proof of Maricopa/Pinal County or Arizona Residency or (Utility Bill, Rent Receipt, Lease Agreement, or Escrow Document)
  • Social Security Number (Card is not required)


  • Saturday, June 15, 2019 - 10:00AM to 12:00PM - Phoenix Indian Center, Computer Lab (2nd Floor), 4520 N Central Ave, Phoenix, AZ 85012
  • Wednesday, June 19, 2019 - 5:00PM to 8:00PM - Mesa Community College, LB-245 (Library 2nd Floor), 1833 W Southern Ave, Mesa, AZ 85202
  • Thursday, June 27, 2019 - 5:00PM to 8:00PM - Phoenix College, L-022 Encanto Classroom (Library Lower Level), 1202 W Thomas Rd, Phoenix, AZ 85013
  • Monday, July 8, 2019 - 5:00PM to 8:00PM - Phoenix College, L-022 Encanto Classroom (Library Lower Level), 1202 W Thomas Rd, Phoenix, AZ 85013
Please indicate which Summer Academy Orientation you will be attending:*


  • AIS 103 - Introduction to Indigenous Cultures
  • BPC 101AA - Introduction to Computers I
  • COM 110AA - Interpersonal Communication
  • CPD 115 - Creating College Success

Students will have the freedom to choose their class but seating is on a first-come first-served basis. Students wanting to enroll in a particular class are advised to attend an early orientation date with all their required documents. Students will not be enrolled in a class without submitting all four required documents.


Because each day is scheduled differently, transportation will be provided daily for students from a designated pick up location and will be dropped off at the same location. Early dismissal of a student is highly discouraged because they will miss valuable information at employee site visits and possibly receive a lower grade. People who are permitted to pick up a student should be listed in the Parent/Guardian Information and Emergency Contact section of this application. Students are not permitted to ride in vehicles without proper authorization by the parent/guardian. If a student is picked up early, proper identification must be presented to the Van Driver/Chaperone/Bus Driver or the student will be transported back to the original drop off location.


(Please initial next to each statement below)

I hereby authorize and give full consent to the PHOENIX INDIAN CENTER, INC. to transport my child.

This Release, Indemnity, and Assumption of Risk statement covers all activities, events, sessions, meals, occurrences, participation, observation, and travel between activities, associated with this project. I hereby give permission for my child to participate. For my child, I agree to assume the risk of any events associated with my child’s participation, observation, or other activities that may result in any harm, injury, illness, damage or loss to my child. I hereby release, waive, and hold harmless Phoenix Indian Center, or other organizations involved in the program or any of these organizations agents, personnel or volunteers from any claims, liability, or responsibility for any such injury, illness, damage or loss. I understand the activities are voluntary, and I agree to accept the responsibility for my child’s personal safety and participation in the program. I consent to the provision of emergency medical treatment for my child to the extent the treatment is necessary in the medical opinion of the doctor rendering the treatment. If I have any concerns about my child’s ability to participate in any event or activity associated with the Phoenix Indian Center, I agree to discuss my concerns with my child’s physician before signing this form.

Program Participant Responsibilities:

  • Showing up on-time for scheduled activities/events/classes.
  • Informing staff of contact information changes as well as concerns related to the program or activities; e.g. transportation, housing, personal issues, etc.
  • Agreeing to abide by all rules and standards, established by the Phoenix Indian Center Inc. (e.g. no smoking in the building, inappropriate language, improper use of equipment, no drugs, alcohol, and firearms allowed on the premises.)

Phoenix Indian Center Staff Responsibilities:

  • Explanation of available program activities to students
  • Assistance with developing goals for students
  • Education, advisement and assistance to achieve program goals as identified
  • Referral for outside services not provided by program/agency
  • Coordination of services with other agencies related to student’s progress

This agreement will remain in effect for the duration of the program. The Phoenix Indian Center personnel will be advised of any violations of agreement and appropriate action may be taken to remedy the situation, including family discussions or possible suspension or termination from the program.

I have read and understand the terms and conditions of this registration form and further understand my responsibilities as a program participant. I understand this authorization shall be in effect for the direction of my acceptance and participation in the program. By signing below, you indicate that you want to participate in this exciting program and that your parent/guardian supports your participation.

Electronic Signature Option:
By typing your name below, you are consenting to use an electronic signature to submit this registration form and indicate that you want to participate in this exciting program and that your parent/guardian supports your participation.

Upon receipt of form you will be contacted for the next steps.
Parent/Guardian Signature:*
Student Signature:*
Today's Date:*
If a student referred you to this program, let us know who: