Native Village of Eyak
Tribal Circle Program
Request and Consent for Circle Process
I, ________________________________, request the Native Village of Eyak Program to convene a
Circle for the purpose of addressing the following circumstances:
I accept responsibility for my actions in regard to these circumstances and am prepared to willingly
participate in the Circle, abide by its guidelines, and fulfill its requirements to the best of my ability.
Signature of Client: _____________________________________ Date: ________________________
Signature of Witness: ____________________________________ Date: ________________________
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I, ________________________________ (parent or guardian), consent to the participation of the youth
named above in a Circle to address the described circumstances. I agree to participate in the Circle, abide
by its guidelines, and support its decisions to the best of my ability.
Signature of Parent/Guardian: ___________________________ Date: ________________________
Signature of Parent/Guardian: ___________________________ Date: ________________________
Signature of Witness: _________________________________ Date: ________________________
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