Minnesota Indian Women’s Sexual Assault Coalition

1619 Dayton Ave. Suite 202 St. Paul, MN. 55104 (651) 646-4800 or 1-877-995-4800

13th Annual
Native
Girl’s Retreat! / 2nd
Native
Boy’s Retreat!
Camp Miller, Sturgeon Lake, Duluth, MN.
Same Camp, Separate Lodges, fully chaperoned
June 27, 28, 29, 2017

This year, we have a very powerful youth leadership project to work on!

Sexual violence can happen or impact us, no matter our age, gender, abilities, or sexual orientation.

What if you could get youth specific training on ways to advocate for a young survivor of sexual assault?

What if you could become a facilitator or trainer for other youth?

MIWSAC is developing a Native Youth Specific, 40-Hour Sexual Assault Advocacy Training.

If you are interested in helping us make this into a great youth curriculum, join us in June!

We will still have fun activities like kayaking, and swimming, but come ready to work too!

FAX OR EMAIL REGISTRATION/RELEASE FORMS TO:

Deb at

Office 651-646-4800 or Office Fax 651-646-4798

MINNESOTA INDIAN WOMEN’S SEXUAL ASSAULT COALITION

REGISTRATION and PARENTAL CONSENT FORM

Last Name, First Name & Middle Initial of child

Address

City State Zip Code

Home Phone Work/Cell Phone

Date of Birth

APPROVAL BY GUARDIAN

By signing this form I have knowledge and have given approval for my child to participate in the Native Girls/Boys Retreat, Camp Miller, Sturgeon Lake, near Duluth MN. June 27th to 29th, 2017.

Signature of Legal Guardian ______Date______

MEDICAL RELEASE

In the event of illness or injury occurring to my child while involved in this trip, I consent to X-ray, examination, anesthesia and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be made.

Insurance Company and Policy Number

Physician Name and Phone Number

Minnesota Indian Women’s Sexual Assault Coalition · 1619 Dayton Ave, Suite 202 · St. Paul, MN 55104 · 1-877-995-4800

MINNESOTA INDIAN WOMEN’S SEXUAL ASSAULT COALITION

CHILD EMERGENCY CONTACT FORM

Child’s Name______

Address______

Date of Birth______Grade ______

Tribal Affiliation______

Phone Number______

Parent/Guardian______

Emergency Contact Name & Number______

Any allergies or medical conditions we should be aware of?______

______

Foods that child can or can not eat:______

______

Anything else we should know about your child?______

______

______

______

______

Minnesota Indian Women’s Sexual Assault Coalition · 1619 Dayton Ave, Suite 202· St. Paul, MN 55104

651-646-4800 or toll free 1-877-995-4800

MINNESOTA INDIAN WOMEN’S SEXUAL ASSAULT COALITION

MEDIA RELEASE FORM

Dear Participants,

The Minnesota Indian Women’s Sexual Assault Coalition takes photos and often video-records our events in order to create public awareness material around the topic of sexual violence awareness and prevention. At this year’s retreat we are creating a Native Youth Specific 40 Hour Sexual Assault Advocacy Training based off of our adult Native Specific Sexual Assault Advocacy Training. You child will be helping us to develop this curriculum, and could potentially become peer to peer trainers with MIWSAC Staff.

The following are the guidelines we will follow if you decide to participate:

1. Both Coalition members and participants will work together on the public awareness material.

2. The final project may be used in the future by MIWSAC.

3. The information you share will be used in a good way.

4. You may change your mind about the use of your contribution at any time prior to final editing of the items we produce and footage will not be used.

5. We will only use your contribution if you sign and date the release at the bottom of this page.

6. To participate you must sign and date the release at the bottom of the page.

We honor your commitment to ending violence against women, girls and boys.

For more information contact MIWSAC at 651-646-4800 or 1-877-995-4800. Miigwech!

RELEASE

I understand that I am giving my permission to the Minnesota Indian Women’s Sexual Assault Coalition for the purpose of inclusion in public awareness material about sexual violence awareness and prevention. My contribution will not be used for any other purposes than those recited in this release unless I give my written permission. I am participating without expectation of compensation and will only be acknowledged by name if I check the box below.

______

Signature Date

(Check) ____Do _____Do NOT want to be acknowledged by name in written materials.

Print Name and Address:

Minnesota Indian Women’s Sexual Assault Coalition · 1619 Dayton Ave, Suite 202 · St. Paul, MN 55104

651-646-4800 or toll free 1-877-995-4800

Retreat items to bring & not to bring

Clothing

Rain gear and boots

Swimsuit

Tennis or hiking shoes

Warm Jacket

Sweaters

Changes of outer clothing

Changes of under clothing

Several pairs of socks

One pair of other shoes

Personal Gear

Towel, Soap, and shampoo

Toothbrush & paste

Water bottle

Insect repellent

Sun block

Sleeping Bag

Pillow

Optional Personal Gear

Long Ceremony skirt (for girls)

Camera

Flashlight

Sunglasses

DO NOT BRING

Radios, CD Ro Mp3 players

Electric appliances (hairdryers curling irons)

Aerosols

Chewing gum

Non-recyclable items

Plan on bringing used batteries home