Registration: Native Men's Wellness Workshop Survey

Please complete this registration for EACH PERSON who will be attending the 2012 Native Men's Wellness Conference. This will help us get a head count on meals and materials needed. Thank you.

1. My contact information:

My contact information: Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2. Tribal Affiliation - community

Tribal Affiliation - community Chehalis

Nisqually

Squaxin Island

Skokomish

Shoalwater Bay

Other (please specify)

3. Room request:

Room request: Standard Deluxe King Non-Smoking

Standard Deluxe Double Queen Non-Smoking

Accessible King Non-Smoking

No room needed (not staying at Little Creek)

No room needed: sharing room with other participant

Other:

4. Shirt Size

Shirt Size Medium

Large

XLarge

2XLarge

3XLarge

4XLarge

5. I am a (check all that apply):

I am a (check all that apply): Cancer survivor

Caregiver

Other

*
6. In consideration of accepting my registration, I, intending to be legally bound for myself, my heirs, executors and administrators, do hereby release and discharge SPIPA, its consortium tribes and any and all staff and sponsors from any and all liability arising from illness, injuries, and damages that I may suffer as a result of my participation in this conference. I grant SPIPA permission to use my photo or likeness for SPIPA related activities.

In consideration of accepting my registration, I, intending to be legally bound for myself, my heirs, executors and administrators, do hereby release and discharge SPIPA, its consortium tribes and any and all staff and sponsors from any and all liability arising from illness, injuries, and damages that I may suffer as a result of my participation in this conference. I grant SPIPA permission to use my photo or likeness for SPIPA related activities. By checking this box, I certify that I have read and agree to the above information.

This conference is intended for Men only; spouses/partners are welcome, however, we request that small children and other family members please make other arrangements while men are attending the conference. MEALS AND LODGING ARE FOR REGISTERED MEN AND REGISTERED SPOUSES/PARTNERS. Sorry for any inconvenience.

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Registration

1. My contact information:

2. Tribal Affiliation - community

3. Room request:

4. Shirt Size

5. I am a (check all that apply):

Registration: Native Men's Wellness Workshop
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