Pueblo of Pojoaque
Poeh Cultural Center/Education
Enrollment/Registration Form
78 Cities of Gold Road
Santa Fe, NM 87506
Ph: 505-455-1110 Fax: 505-455-3684
Date__________________________
Name: _________________________________________________ Email: ____________________________
Last
First
_____________________________________________________________________________
Date of Birth
Tribal Affiliation
**Census #*
Current Mailing Address:
_________________________________________________________________________________________
Street
City & State
Zip Code
Telephone: ________________________________________________________________________________
Cell Phone
Home
Message
Please circle one below
_____Pottery
Spring Semester
_____Micaceous Pottery
Summer Semester
_____Stone Sculpture
Fall Semester
_____Jewelry
_____Other________________________________
All information is confidential.
For Official Use Only
Date Received: ___________________________________________________________________________
Received By: ________________________
CIB or Tribal Enrollment Attached or On File : Yes No
Please Circle:
Fee Paid:
(Yes) (No)
If Yes, Cash or Check # __________
Date Paid ________________________
If no payment explain ______________________________________________________________________
Complete Application: (Yes) (No)
Poeh Cultural Center/Education
Registration Form
If under 18 years of age, you must provide parent/legal guardian’s name, address and telephone.
Student Name: _______________________________________________________________________
Last
First
Middle
Parent/Guardian Name: ________________________________________________________________
Last
First
Middle
Current
Mailing
Address: _________________________________________________________________________________
Street
City & State
Zip Code
Telephone: ________________________________________________________________________________
Home
Work
Message
Poeh Cultural Center/Education Registration Form
Student Agreement and Release Waiver
1. I, ______________________________, am committed to completing the entire course of study as indicated
below:
(Please print name)
Beginner
Intermediate Advanced
Mentor
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
Pottery ____________
Sculpture
Jewelry
Other ______________
‫ٱ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
‫ڤ‬
2. I am committed to attending all classes on a punctual and regular basis. I am committed to completing all
assignments on time, and to the best of my ability. I understand that only the instructor, Arts Training
Coordinator, and Director may excuse absences.
3. I have read the Poeh Cultural Center/Education policies. I understand that I may be dismissed from the
program if I violate these policies.
4. I understand that in the course of my studies I will use Poeh Cultural Center/Education tools, materials, and
supplies. I understand that I must pay for their use. I agree to pay a Poeh Cultural Center /Education Student
Use and Registration Fee in the amount
of $65.00 for the Pottery course, and $75.00 for the Sculpture, Wood and Jewelry courses. (Fees are non-
refundable and are subject to change without notice.)
5. I agree to pay the amount of $ _________ for the __________________________(other) course(s) of study.
Release
Students are solely responsible for their safety. During the course of the program, the student agrees not to hold liable the
Poeh Cultural Center/Education, Pojoaque Pueblo, private vehicle owners, or owners of private facilities (i.e., artist’s studio,
art gallery, etc.) for any incidents occurring outside the scope of the currently maintained insurance. All programs,
application, techniques, ideas, formulas, photographs, images, audio tapes, video tapes made by the Poeh Cultural
Center/Education, or any of their authorized contractors, independent contractors, during the course of instruction shall
remain the sole property of the Poeh Cultural Center/Education. Any and all rights to the above shall be the sole property of
the Poeh Cultural Center/Education. Photographs, images, or audiotapes may be made of students or their work at any time
with permission.
_____________________________________
Student
____________________________________
Date
________________________________________
Lynda Romero, Assistant Director
_____________________________________
Date
________________________________________
Phillip Karshis, Director
_____________________________________
Date
Page 3
Poeh Cultural Center/Education
Registration Form
Zero-Tolerance Substance Abuse Policy
Use of addicting drugs, intoxicants or alcohol impairs your job and school performance and such substance abuse will
not be tolerated under any condition.
The zero-tolerance policy applies to all students and instructors in the Poeh Cultural Center/Education.
The zero-tolerance policy does not permit the unauthorized use of or transfer of illegal drugs, drug paraphernalia,
controlled substances, intoxicants, or alcohol.
The zero-tolerance policy does not permit staff, student and instructors to attend class under the influence of illegal
drugs, controlled substances, intoxicants or alcohol. Students determined to be under the influence will be asked to
leave on their own recognizance or escorted off the Pueblo of Pojoaque reservation.
The zero-tolerance policy protects the safety, health and welfare of yourself and those around you. The
zero-tolerance policy protects against the potentially dangerous misuse of art materials and machinery. Even the
use of legal painkillers or cough syrups with codeine can alter alertness and jeopardize your safety, therefore, it is
the students obligation to notify instructors if you are under medical prescription.
By signing your name below, you agree to abide by the terms of the zero-tolerance substance abuse policy of the
Poeh Cultural Center/Education. Any violation of the substance abuse policy will result in your immediate dismissal
from the program and possible criminal or civil sanctions in the Pueblo of Pojoaque Tribal Court.
__________________________________________
Student’s Signature
______________________________________
Date Signed
_________________________________________
Signature of Parent/Legal Guardian
______________________________________
Date Signed
(if student is under 18)
_________________________________________
Director’s Signature
______________________________________
Date Signed
_________________________________________
Instructor’s Signature
______________________________________
Date Signed
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Poeh Cultural Center/Education
Registration Form
Where did you hear about our Program? 

Newspaper
Radio
Do you have any experience in self-employment?
 Student
 Friend/Relative
Yes
 Tribal Bulletin/Newsletter
 Other________________
No
If yes please explain: ________________________________________________________________________
__________________________________________________________________________________________
Do you have experience in the sale of your artwork?
Yes
No
If yes please explain: ________________________________________________________________________
The Program requires 8 or16 weeks of training. Will you commit to the entire period of training?
Yes
No
If no, what factors will keep you from attending on a consistent basis? ________________________________
Are you interested in college credit?
Yes
No
*If you wish to earn college credit, you will need to apply and pay for all registration fees at Northern New Mexico
Community College. Please note that these fees are in addition to the Poeh Cultural Center/Education fees.
Medical Condition:
Yes
No
If yes please explain: ________________________________________________________________________
__________________________________________________________________________________________
Do you take medications on a regular basis?
Yes
No
If yes please explain: ________________________________________________________________________
__________________________________________________________________________________________
Please write a brief explanation of any previous experiences in the arts, and your interest in applying to the
Poeh Cultural Center/Education:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Page 5
Poeh Cultural Center/Education
Field Trip Release Waiver
Field Trip ______________________________________
Date ______________________________
The student acknowledges that they are responsible for their own safety. During the course of the program, the
student agrees not to hold liable the Poeh Cultural Center/Education, Pojoaque Pueblo, private vehicle owners, or
the owner of any private facility (i.e., artist’s studio, art gallery, etc.) for any incidents occurring outside the scope
of the currently maintained insurance. I hereby waive the rights to photographs, images, or audiotapes made by
Poeh Cultural Center/Education or any of there authorized contractors of my self or my work during the course of
the program.
Student ________________________________________
Date______________________________
Phillip Karshis, Program Director ____________________
Date ______________________________
or Lynda Romero, Assistant Director__________________
Date ______________________________
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Poeh Cultural Center/Education
Dear Student,
If you invite a guest along, they must read and sign the waiver below. Thank you.
Field Trip Release Waiver for Non-Poeh Cultural Center/Education
The non-Poeh Arts participant acknowledges that they are responsible for their own safety. During the course
of the program, the non-Poeh Cultural Center/Education participant agrees not to hold liable the Poeh Cultural
Center/Education, Pojoaque Pueblo, private vehicle owners, or the owner of any private facility (i.e., artist’s studio,
art gallery, etc.) for any incidents occurring outside the scope of the currently maintained insurance. I hereby waive
the rights to photographs, images, or audiotapes made by Poeh Cultural Center/Education or any of their authorized
contractors of “myself or my work” during the course of the program.
Non-Poeh Cultural Center/Education
Participant _______________________________________
Date _____________________________
Phillip Karshis, Program Director ______________________
Date _____________________________
Lynda Romero, Assistant Director_________________________
Date_____________________________
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