Kidney Keepers Wellness Club Application

To register, fill out the form below in your browser or download and print off the file below and fill it out on paper.

kidneykeepersRegForm3.19.18.pdf
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03/20/2018 5:31 PM

For more information please email:  KidneyKeepers@cskthealth.org

Kidney Keepers Wellness Club Form

We are a wellness group funded by the Special Diabetes Program for Indians Grant through CSKT Tribal Health. Our aim to raise awareness about diabetes and kidney disease in Native Communities. Our goal is to prevent and control diabetes in our lives, our families, and our communities. We sponsor monthly activities and participate in organized events throughout the year. We welcome you to join us!
Name(*)
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Phone(*)
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Date of Birth(*)
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Eligible for Services at Tribal Health?(*)
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Email Address(*)
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Facebook User?(*)
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What community do you live in?
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Shirt Size
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Pant Size
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Preffered method of exercise
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Other
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Expected Level of Engagement
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VIDEO/PHOTOGRAPH RELEASE FORM

I hereby grant CSKT Tribal Health permission to use photographs and/or video recordings of me on Tribal Health and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose.
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AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:
  • That I am participating in the Health & Fitness Classes or Exercise Programs offered by the Tribal Community Fitness Center during which I will receive information and instruction about health and fitness. I recognize that fitness programs require physical exertion, which may be strenuous and may cause physical injury and I am fully aware of the risks and hazards involved.
  • I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Health & Fitness Classes or Exercise Programs. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in the Exercise Classes or Exercise Programs.
  • In consideration of being permitted to participate in the Health & Fitness Classes or Exercise Programs, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the pro- gram.
  • In further consideration of being permitted to participate in the Health & Fitness Classes or Exercise Programs, I knowingly, voluntarily and expressly waive any claim I may have against the Tribal Community Fitness Center and the Confederated Salish & Kootenai Tribes for injury or damages that I may sustain as a result of participating at the Tribal Community Fitness Center. I, my heirs or legal representatives forever release, waive, discharge and covenant to sue the Tribal Community Fitness Center and the Confederated Salish & Kootenai Tribes for any injury or death caused by their negligence or other acts. I have read the above release and waiver of liability and fully understand its contents.
By submitting this application and entering my name in the box below, I voluntarily agree to the terms and conditions stated above. If participant is less than 18 years of age, the legal guardian of the participant that is submitting this form must also consent to the terms and conditions stated in this form.
Signature(*)
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Guardian's Signature
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