Na-ha-shnee Application

WSU Health Sciences Spokane
June 14 – 26, 2020

Thank you for applying to attend the 25th Annual Na-ha-shnee Native American Health Sciences Institute hosted by Washington State University Health Sciences Spokane. If you have any questions about this application, please contact the Native American Outreach Health Sciences Coordinator, Evanlene Melting Tallow at e.meltingtallow@wsu.edu or 509-358-7833.

Na-ha-shnee is a free 12-day career exposure and college preparation experience for Native American and Alaska Native students interested in health careers. This application must be completed by both the current 9th-12th grade student interested in attending and their parent/guardian. In this application, students are asked to include a short-written response. In order to complete the application students must submit a current high school academic transcript. Transcripts must include a cumulative GPA (cannot be a recent grade report that does not list all high school coursework) and all high school courses taken so far. Transcripts can be submitted via email, fax, or mail:

Evanlene Melting Tallow
WSU Health Sciences Spokane
P.O. Box 1495
Spokane, Washington 99202-1495
Fax: 509-358-7505.

The application deadline is 5 p.m. (PST) on Wednesday, April 15, 2020.

Apply:

For recruitment purposes, please let us know how you heard about Na-ha-shnee:*
- Someone from WSU came to my school and asked me to apply
- Someone from WSU talked to me at a conference and asked me to apply
- School teacher / counselor asked me to apply
- Family member asked me to apply
- I found the information online and decided to apply
- I attended Na-ha-shnee before and it was great!
- Other
Participant Information
Gender*
- Male
- Female
- Prefer to self-describe
Self-description
Name*
First Last
Birth Date*
Month
Day
Year
Home Phone Number*
Cell Phone Number*
Participant's Email Address*
Your Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have access to reliable Internet access that can connect to a tablet or laptop?*
- Yes
- No
Tribal affiliation. Please list tribe(s):*
Are you an enrolled tribal member?*
- Yes
- No
- I am not enrolled, but I am a descendant
You do not need to be enrolled to participate in Na-ha-shnee and you do not need to submit any documentation of your enrollment status.
T-shirt size (adult unisex/men's sizes)*
- Small
- Medium
- Large
- X-Large
- XX-Large
- XXX-Large
Parent/Guardian Contact Information (In case of emergency, this parent/guardian will be the first person contacted.)
Parent/Guardian First, Middle and Last Name*
Parent/Guardian Primary Phone Number*
Parent/Guardian Secondary Phone Number
Parent/Guardian Email Address*
Parent/Guardian Address (only if different from student)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact (other than parent/guardian contact listed above)
Name (First, Middle, Last)*
Primary Phone Number*
Secondary Phone Number
Participant's Education Background
School Presently Attending (School Name, City, State)*
Current Grade Level (2019 - 2020 school year)*
- 9th
- 10th
- 11th
- 12th
Current Cumulative GPA/Grade Average*
Do you plan to attend a two- or four-year college?*
- Yes
- No
Did or will one of your parents graduate from a college, university or technical institute?*
- Yes
- No
Do you currently have a CPR/First Aid certification that will not expire before June 2020?*
- Yes
- No
*We pay for Na-ha-shnee students to receive CPR/First Aid training. If you are already trained and have a certification card you are not required to participate in the training.
Academic Interests
What are your top three career interests at this present time?*
Statement of Interest (to be completed by Na-ha-shnee Participant)
In 100-200 words or more, tell us about: Your specific health career interests and why you would like to become a health professional. Any health issues that you would like to see changed in communities. What you expect to get out of your experience at Na-ha-shnee Native American Health Science Institute. Please Note: Each letter of interest will be rated using a rubric. In the rubric the highest possible scores are based on whether the letter demonstrates a strong interest in health science and is: - Clearly organized (there is a clear flow of ideas). - Free of errors in spelling and grammar. - Formatted into clear paragraphs.
Please upload your Statement of Interest*
Max. file size: 195 MB.
Participant Medical Information
Name of Participant Primary Medical Provider*
Phone Number of Primary Medical Provider*
Insurance/Health Coverage Company*
Policy Number*
Subscriber's Name*
Insurance/Health Coverage Company Phone Number*
Allergies*
- No known allergies
- Allergic to food(s)
- Allergic to medication(s)
- Allergic to the environment (insects, hay fever, etc.)
- Other
Please detail any allergies here:*
An emergency care plan signed by physician is required to attend Na-ha-shnee if a participant has a life-threatening allergy. This will be requested when selected to participate in the institute. If the participant has a life-threatening allergy please select the button below.
- This Participant has a Life-threatening Allergy
Diet/Nutrition*
- Participant eats a regular diet
- Participant has special dietary restrictions
Please describe any special dietary needs:
Medications (to be completed by parent/guardian)
Medication is any substance a person takes to maintain and/or improve their health. This includes all prescription medication, as well as all over-the counter drugs that are potentially hazardous if misused (e.g., Tylenol, aspirin, cough medicine, cold tablets, vitamins & natural remedies. All medications must be in their original containers. Prescriptions must have the child’s name and how the medication should be given printed on the prescription container. Please send only those medications that are necessary. Participants are required to turn medications in to staff upon arrival.
Will the participant bring any medications?*
- This participant will not take any daily medications
- This participant will bring medication(s) to be administered by the camp nurse
Medication name, amount & time administered, & reason for taking for each medication:
To be completed by parent/guardian
Participant can have over the counter medications (Tylenol, Ibuprofen, Aspirin, Cough syrup, Pepto Bismol etc.) as administered and monitored by the camp nurse.
Can the camp nurse provide any type of over-the-counter medications to the participant?*
- Yes
- No
*If you select "No", the camp nurse will not be able to provide any type of over the counter medications to the participant for basic health issues like headache, cramping, stomach ache, etc.
Immunizations*
- Participant is up-to-date on his/her immunizations to include measles and tetanus shots as required by Washington State Law.
- Participant has an immunization exemption on file with his/her school. Parent understands and accepts the risks to child from not being fully immunized
Does the student have any chronic illnesses or chronic conditions that the program needs to be aware of?*
- Yes
- No
If you answered "Yes," please describe the participant's chronic illness or chronic condition:
Does the participant require reasonable accommodation for a disability in order to access or be part of the institute?*
- Yes
- No
If you answered "Yes," please describe:
Health History Signature
This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by me and/or an examining physician. If you fail to advise WSU of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a “need to know” basis with WSU staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Do you agree?*
- Yes
- No
Parent Guardian Name*
First Last
Special Activities during Na-ha-shnee at Washington State University (To be completed by parent/guardian)
In addition to the workshops and games, there are several special activities that we feel are important experiences for youth and for future health leaders.

1. Human Anatomy Lab: The NA-HA-SHNEE Native American Health Sciences Institute will be conducting a tour of the Washington State University Human Anatomy (Cadaver) Lab in Spokane, Washington. During this tour isolated organs/specimens may be viewed, discussed, and touched. Due to the graphic nature of this type of visit, the high school student's parent or legal guardian must give consent and agree to hold Washington State University, the WSU Program in Basic Medical Sciences, and its employees harmless for any adverse or negative reactions that may be incurred during the visit. If you consent to having your student join the tour of the Human Anatomy Lab, Check the first box under "restrictions". If you do not consent to having your student participate, please check the second box and state your restrictions/adaptations in the text box.

2. Sex Education: As a part of our health leadership program we are providing sex education. The topics to be covered are healthy relationships, harm/risk reduction, sexually transmitted infections, birth control methods, and HIV/AIDS information. This session is usually guided by the questions from participants. Please indicate below as to whether or not you want your student to participate in both of these activities or if you would like to request any restrictions on one or both of these activities.
Consent*
- We have reviewed the special activities of the program and feel that our child can participate without restrictions.
- We have reviewed the special activities of the program and feel the student can participate with the following restrictions.
Those restrictions are:
Transportation
Transportation to Na-ha-shnee is not provided. Parents/Legal Guardians are responsible for getting their student to and from the Na-ha-shnee program. Transportation during the program will be provided. Please indicate your transportation plans below:
The participant will:*
- Be dropped off and picked up by a parent/guardian/family
- Other
My transportation plans are:
Contact information consent to be completed by parent/guardian
Often the families of Na-ha-shnee participants request the contact information of other nearby participants in order to independently arrange a carpool to or from camp. If you are willing to share contact information (phone number, email, and city that you live in) for other parent/guardians to contact you about joining a carpool please indicate below:*
- Please share my contact information with the parents of other participants interested in carpooling
- Please do not share my contact information with the parents of other participants interested in carpooling
Personal Respect Contract - to be completed by Na-ha-shnee participant
Respect of self is the first aspect of giving respect to others. We are working to inspire the youth of the Na-ha-shnee Native American Health Science Institute to develop a mature work ethic. We believe work ethic begins with showing respect to self and those that you work with. Behaviors that we would like to see exhibited are the following:

1. BEING ON TIME TO ALL ACTIVIES: This is the most important. (An example of being disrespectful is being late for any of the scheduled activities that have been planned.)

2. When in workshops, show respect by being attentive and listening with interest. (An example of disrespect would be laying your head down on the desk and sleeping or passing notes to each other.)

3. No cell phones or electronics will be allowed during labs or other class activities. If caught using while in class they will be taken away and kept by the counselors until after class.

4. Being professional is being refreshed and ready for the work day. You need your sleep and lights out means time to sleep. [Examples of being disrespectful would be talking after lights out or sneaking out of your room. If caught sneaking out of your room, you will be sent home the next day and a program staff member will call the parent or guardian at the time of being caught, no matter what time (I.E. if caught at 2:00 am, a call will be made at that time.)]

5. Being respectful of fellow participants. This includes no put-downs, no rough horse play, and no foul language.

6. Following directions. WSU college students will be with participants throughout the day, ensuring participation and safety of all. We expect you to comply with their instructions, so program will be enjoyable for everyone.

7. Being respectful of the night staff. We have hired a male and female night crew who will be on duty from 10:30 pm – 6:30 am. They will be patrolling the dorm where we are staying. They will be checking doors and if suspicious, will check the rooms.

8. USE, POSSESSION, OR DISTRIBUTION OF WEAPONS, ALCOHOL, DRUGS, TOBACCO OR ANY OTHER ILLEGAL PRODUCT IS PROHIBITED. YOU WILL BE REPORTED TO LAW ENFORCEMENT AND BE SENT HOME IMMEDIATELY.
YES, I can and will follow these guidelines of respect, and if I show disrespect I will accept the consequences of my actions which may include my parent or legal guardian being contacted and I being sent home.*
- Yes, I agree
- No, I do not agree and understand that I will not be able to participate in Na-ha-shnee
Participant's Name*
First Last
Parent Authorization
Assumption of Risk and Waiver of Liability
I understand that there are risks in participating in lab activities, classroom workshops at the Na-ha-shnee Native American Health Science Institute activities at Washington State University (WSU) Spokane. In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist, including the risk of death or injury to the participant or loss or damage to my property. I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in participating in the Na-ha-shnee activities including lab activities, transportation to and from or during field trips, classroom workshops and recreational activities include, but are not limited to: temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage, head, neck or spinal injuries, loss or use of arms and/or legs, eye damage, disfigurement, burns, drowning or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from the Na-ha-shnee activities that cannot be specifically listed. Further, I recognize that the actions of other participants in the activity may cause harm or loss to the participant or my property.

In Case of Medical Emergency
In an emergency requiring medical attention or a situation reasonably believed to be an emergency by Washington State University (WSU) authorized agents including event staff; I authorize WSU and its authorized agents to obtain emergency medical care for my child. I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the event staff from decisions to seek emergency treatment.

Release of Liability
I release, the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may sustain and/or sustain as a result of death or injury of participant, as a result of or connected with participation in the above event. Participation includes, but is not limited to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of state equipment or facilities for the event whether on or off WSU property.

Images and Recordings Consent
We hereby grant permission to Washington State University (WSU) to photograph or otherwise have images or voice recordings made (including but not limited to digital photographs, video or digital moving images and/or voice recordings), of my child participant for WSU publication or promotional purposes in any medium (including but not limited to print media, newspaper, television, video, motion picture, or Web site on the Internet). I additionally consent to the use of the participant’s name and/or interview comments in connection with WSU publication or promotional purposes in print media, newspaper, television, video, motion picture, or Web site on the Internet. We understand that consent to use of the participant’s likeness or voice recordings is not a condition of participating in the activity and that consent can be refused without any impact in the ability to fully participate in the program. No inducements or promises beyond our acceptance of an opportunity to promote WSU and its programs have been given to the persons signing below. Any other use of images and/or recordings, my name, and/or interview comments requires advance permission. We understand that we can revoke this consent at any time upon notice to WSU, at which time either or both of us will sign a copy of the denial (below) for use of images or voice recording
Do you agree to use of digital images or voice recordings as set forth above?*
- Yes
- No
Parent/Guardian Signature
I (parent/legal guardian of applicant) have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors. I sign it freely and voluntarily.*
- Yes, I agree
Parent/Guardian Name*
First Last
Parents/Guardians: Please note that Na-ha-shnee Participants are not to leave our program to attend activities or events that occur within the duration of the camp. Requests made by students or parents to leave camp to meet with family or attend events will be denied, unless they involve a family emergency.

Na-ha-shnee Application

Apply:

Participant Information

Parent/Guardian Contact Information (In case of emergency, this parent/guardian will be the first person contacted.)

Emergency Contact (other than parent/guardian contact listed above)

Participant's Education Background

Academic Interests

Statement of Interest (to be completed by Na-ha-shnee Participant)

Participant Medical Information

Medications (to be completed by parent/guardian)

To be completed by parent/guardian

Health History Signature

Special Activities during Na-ha-shnee at Washington State University (To be completed by parent/guardian)

Transportation

Contact information consent to be completed by parent/guardian

Personal Respect Contract - to be completed by Na-ha-shnee participant

Parent Authorization

Parent/Guardian Signature