PARENTS/LEGAL GUARDIANS INFORMATION: (Birth date is required for security purposes) PARENT/LEGAL GUARDIAN #1: _ City: County: State: ZIP: Birth date: Gender: Male Female Authorized for pickup? Yes No Home phone: ( ) Cell phone: ( ) Email address: Relationship: Employee of the Chickasaw Nation: Yes No PARENT/LEGAL GUARDIAN #2: _ Birth date: Gender: Male Female Authorized for pickup? Yes No Home phone: ( ) Cell phone: ( ) Email address: Relationship: Employee of the Chickasaw Nation: Yes No ADDITIONAL INFORMATION NEEDED: SECTION A SECTION B Child(ren) live at the above permanent address with parent(s) or legal guardian(s): STOP: If you checked Section A, you do not need to complete Section B of this form. OR If this is not a permanent address for this child, PLEASE GO TO SECTION B EMERGENCY CONTACT INFORMATION: In a shelter Temporarily with more than one family due to loss of job, loss of housing, etc. In a motel, car or campsite. In temporary foster care awaiting placement. Alone without parental support (independent living student). First: Middle: Last: Suffix: Relationship: Home phone: ( ) Cell phone: ( ) Email address: Person(s) authorized for pickup: (Other than parent/guardian) Name: Name: Name: Relationship: Relationship: Relationship: Page 1 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
Child #1 Chikasha Albinachi Cultural Camp Golf 101 Champions Cheerleading Clinic Camps for Ages 8-12 Camps for Grades 3-6 or Ages 8-13 Boys Basketball Camp Environmental Camp Halloween Lock-in Winter Softball Clinic Camps for Ages 8-14 Camps for Grades 4-8 or Ages 9-13 Winter Baseball Clinic Yaakni Inaalhpisaat Chokma Camp Survivor Tennis Camp (Judicial Camp) Camps for Grades 3-12 or Ages 8-18 Youth Academy Champions Football Clinic Chickasaws are Playing Camp Fall Break CNASA - Chickasaw Nation Hayaka Unta Camp (Fall 2018) Aviation and Space Academy Hayaka Unta Camp (Spring 2019) Ikbi Holisso Book Creation Camp Camps for Grades 7-12 or Ages 12-18 Page 2 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
Child #2 Chikasha Albinachi Cultural Camp Golf 101 Champions Cheerleading Clinic Camps for Ages 8-12 Camps for Grades 3-6 or Ages 8-13 Boys Basketball Camp Environmental Camp Halloween Lock-in Winter Softball Clinic Camps for Ages 8-14 Camps for Grades 4-8 or Ages 9-13 Winter Baseball Clinic Yaakni Inaalhpisaat Chokma Camp Survivor Tennis Camp (Judicial Camp) Camps for Grades 3-12 or Ages 8-18 Youth Academy Champions Football Clinic Chickasaws are Playing Camp Fall Break CNASA - Chickasaw Nation Hayaka Unta Camp (Fall 2018) Aviation and Space Academy Hayaka Unta Camp (Spring 2019) Ikbi Holisso Book Creation Camp Camps for Grades 7-12 or Ages 12-18 Page 3 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
Child #3 Chikasha Albinachi Cultural Camp Golf 101 Champions Cheerleading Clinic Camps for Ages 8-12 Camps for Grades 3-6 or Ages 8-13 Boys Basketball Camp Environmental Camp Halloween Lock-in Winter Softball Clinic Camps for Ages 8-14 Camps for Grades 4-8 or Ages 9-13 Winter Baseball Clinic Yaakni Inaalhpisaat Chokma Camp Survivor Tennis Camp (Judicial Camp) Camps for Grades 3-12 or Ages 8-18 Youth Academy Champions Football Clinic Chickasaws are Playing Camp Fall Break CNASA - Chickasaw Nation Hayaka Unta Camp (Fall 2018) Aviation and Space Academy Hayaka Unta Camp (Spring 2019) Ikbi Holisso Book Creation Camp Camps for Grades 7-12 or Ages 12-18 Page 4 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
Child #4 Chikasha Albinachi Cultural Camp Golf 101 Champions Cheerleading Clinic Camps for Ages 8-12 Camps for Grades 3-6 or Ages 8-13 Boys Basketball Camp Environmental Camp Halloween Lock-in Winter Softball Clinic Camps for Ages 8-14 Camps for Grades 4-8 or Ages 9-13 Winter Baseball Clinic Yaakni Inaalhpisaat Chokma Camp Survivor Tennis Camp (Judicial Camp) Youth Academy CNASA - Chickasaw Nation Aviation and Space Academy Ikbi Holisso Book Creation Camp Camps for Grades 3-12 or Ages 8-18 Champions Football Clinic Chickasaws are Playing Camp Fall Break Hayaka Unta Camp (Fall 2018) Hayaka Unta Camp (Spring 2019) Camps for Grades 7-12 or Ages 12-18 FOR MORE THAN FOUR CHILDREN PLEASE FILL OUT AN ADDITIONAL APPLICATION Page 5 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
Phone: (580) 272-5716 Fax to: ( 580) 436-7288. NOTE: DEADLINE FOR ALL CAMPS APRIL 15, 2018 Information on date, location and transportation for each camp CHIKASHA ALBINACHI Cultural Camp (AGES 6 11) Dates: May 22-23, 2018 Location: Chickasaw Cultural Center, Sulphur Transportation: not provided CAMP SURVIVOR (GRADES 4-8 or AGES 9-13) Dates: May 29 June 1, 2018 Location: Camp Classen, Davis Transportation: not provided ENVIRONMENTAL CAMP (AGES 8-12) Dates: May 30 June 1, 2018 Location: Ada Transportation: not provided CNASA - CHICKASAW NATION AVIATION AND SPACE ACADEMY (AGES 10-18) Dates: June 4 8, 2018 Location: Science, Technology and Math Academy, Ada Transportation: provided for CNASA scholarship students who live out of state, but availability limited. GOLF 101 (GRADES 3-6 or AGES 8 11) Dates: June 4 5, 2018 Location: WinStar Golf Course, Thackerville Transportation: provided GOLF CAMP II (GRADES 7-12 OR AGES 12-18) Dates: June 6-7, 2018 Location: WinStar Golf Course, Thackerville Transportation: provided NATIVE AMERICAN JR. OPEN GOLF TOURNAMENT (GRADES 3-12 or AGES 8-18) Note: This is an open golf tournament for any Native American youth. This is also the qualifier for Team Chickasaw Golf. There is an entry fee that is due the day of the tournament. Date: June 8, 2018 Location: WinStar Golf Course, Thackerville Transportation: not provided FCA COMPETITORS CAMP (AGES 11-14) Dates: June 8 11, 2018 Location: Camp Walk On Water, Gerty Transportation: not provided SPACE CAMP (Huntsville, AL) (AGES 9-18) Dates: June 10-16, 2018 Location: U.S. Space & Rocket Center, Huntsville, AL Transportation: provided, but availability is limited. TENNIS CAMP (ages 6-18) Dates: June 11-12, 2018 Location: Ada Tennis Center, Ada Transportation: provided FCA XTREME CAMP (AGES 15-18) Dates: June 18-22, 2018 Location: Crosspoint Camp, Kingston Transportation: not provided LIGHTHORSE YOUTH POLICE ACADEMY (AGES 9 15) Dates: June 18-22, 2018 Location: Lighthorse Police Department, Ada Transportation: not provided CHAMPIONS FOOTBALL CLINIC (GRADES 3-12 or AGES 8 18) Dates: June 21-23, 2018 Location: Ada High School Indoor Field, Ada Transportation: provided CHAMPIONS CHEERLEADING CLINIC (AGES 6-18) Dates: June 22-23, 2018 Location: Family Life Center Gym, Ada Transportation: provided Page 6 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018
IKBI HOLISSO Book Creation CAMP (AGES 10-18) Dates: June 26-29, 2018 Location: TBD Transportation: not provided YAAKNI INAALHPISAAT CHOKMA JUDICIAL CAMP (AGES 8-14) Dates: June 28-29, 2018 Location: Ada Transportation: not provided TANUMPO HOSA APISA CLINIC SHOOTING CAMP (GRADES 7 12 or AGES 12-18) Dates: July 5-6, 2018 Location: Davis, Oklahoma Transportation: provided GIRLS BASKETBALL CAMP (GRADES 3 12 or AGES 6-18) Dates: July 9-10, 2018 Location: Oklahoma City University Gym Transportation: Participants ages 6-12 will be provided transportation each day to the camp destination. BOYS BASKETBALL CAMP ( GRADES 3 12 or AGES 6-18) Dates: July 11-12, 2018 Location: Oklahoma City University Gym Transportation: Participants ages 6-12 will be provided transportation each day to the camp destination. CHICKASAW ARTS ACADEMY (GRADES 3 12 or AGES 8 18) Dates: July 14-28, 2018 Location: East Central University, Ada Transportation: N/A FALL (2018) HAYAKA UNTA CAMP (GRADES 3-12 OR AGES 8 18, Chickasaw Families) Dates: October 12-14, 2018 Location: Camp Goddard, Sulphur Transportation: not provided CHIKASHSHAAT HOOCHOKOSHKOMO Chickasaws are Playing Camp (GRADES 3-12 or AGES 8-18) Dates: Fall Break Location: Chickasaw Cultural Center, Sulphur Transportation: not provided HALLOWEEN LOCK-IN (GRADES 3-6 OR AGES 8-13) Dates: October 19-20, 2018 Location: Andy Alligator s, Norman Transportation: provided WINTER BASEBALL CLINIC (GRADES 3-12 OR AGES 6-18) Dates: December 20-21, 2018 Location: D-Bats in Oklahoma City Transportation: provided WINTER SOFTBALL CLINIC (GRADES 3-12 OR AGES 6-18) Dates: December 27-28, 2018 Location: D-Bats in Oklahoma City Transportation: provided SPRING (2019) HAYAKA UNTA INTO THE WOODS CAMP (GRADES 3-12 OR AGES 8-18) Dates: April 5-7, 2019 Location: Camp Goddard, Sulphur Transportation: provided Page 7 of 7 Form no. 04004-2018 CS-YS Rev. 1/2018