Rock to Rock Relay Run

General Info

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First Name:

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Middle Initial:

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Last Name:

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Date of Birth:

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Phone Number:

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Emergency Contact:

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Address:

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Zip Code:

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Chapter:

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Tribe:

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Email Address:

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Health Background Information

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Current Diabetes Status

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Family History:

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Known Allergies:

Current Medication:

Do you have a Medication Condition?

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Stage Course info

Shuttle Service:

yes

no

Consent and Release Form

Consent to Release Information/Wavier/Media Release

Part 1: Consent to Release Information:
I hereby give my consent to release information to participate in Navajo Nation
Special Diabetes Program (NNSDP) Activity/Events. I understand that the
information collected is confidential and cannot be disclosed without my written
consent. NNSDP will store and secure sensitive information in a manner that will
maintain my confidentiality according to the Navajo Nation Privacy Act.

Part II – Waiver:
I wish to participate in _______________________________event. I give
statement that I am in good health and there is no medical reason that I should
not attempt such a feat. I recognize the participation in recreation activities, even
when well supervised and managed, pose a risk to myself including disabilities,
injuries, and death, and I agree to such risk. In case of an injury, I authorize the
Navajo Nation Special Diabetes Program staff and participating
sponsors/volunteers to render first aid and/or obtain immediate medical
treatment she/he deems necessary for myself/child(ren) welfare. I further
understand and agree that I will be financially responsible for all charges and fees
incurred in the rendering of said treatment, regardless of whether my medical
insurance would cover such charges and fees. I agree that all exercises activities
shall be undertaken by me at my sole risk, and the Navajo Nation Special Diabetes
Program and participating sponsors shall not be liable for any claims, demands,
actions, damages, that occur to me or my property arising out of or connected
with the use of services or activities and I do hereby expressly forever release and
discharge Navajo Nation Special Diabetes Program and participating sponsors
from all such claims demands, injuries, damages, actions or causes of action, and
from all acts that are active or passive negligence on the part of Navajo Nation
Special Diabetes Program and participating sponsors.

Part III: Photo Release:
I hereby release and authorize the Navajo Nation Special Diabetes Program, its
assigns and / or clients, full rights to use my voice, audio recording, video or photo
for the purpose of advertising, marketing, of promotion on its behalf or on behalf
of its clients.

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Electronic Acknowledgement

By checking this box I acknowledge that I understand and have read the Consent to Release Information/Waiver/Media Release Form. That all the information filled in above is correct and true in nature.

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