May 22-23, 2018 Northwest Tribal Tobacco Summit registration

Registration Form

Northwest Tribal Tobacco Summit - Culture as Prevention
Date: Tuesday, May 22, 2018 and Wednesday, May 23, 2018
Time: 8:30am to 5:00pm
Location: Kiana Lodge

14976 NE Sandy Hook Rd.

Poulsbo, WA 98370

Meeting Location Phone: 866-738-4307

Registration Deadline: May 11, 2018

Question Title

* 1. Contact Information

Name:

Position:

Tribe/Organization:

Address:

City:

State:

ZIP Code:

Email Address:

Phone Number:

Question Title

* 2. Does your tribe have a policy in place addresssing:

	Yes	No	In Progress
Tobacco	Tobacco Yes	Tobacco No	Tobacco In Progress
Physical Activity	Physical Activity Yes	Physical Activity No	Physical Activity In Progress
Nutrition	Nutrition Yes	Nutrition No	Nutrition In Progress
Wellness in the Workplace	Wellness in the Workplace Yes	Wellness in the Workplace No	Wellness in the Workplace In Progress

Question Title

* 3. Would you be willing to share your tribal policies?

Yes

Depends - Clarification:

Question Title

* 4. Do you use culture in your tobacco program?

Yes

Question Title

* 5. If your tobacco program incorporates culture would you be willing to share as part of a group panel?

Yes

Maybe

Other comments

Question Title

* 6. Do you have any dietary considerations?

Vegetarian

Vegan

Gluten Free

Other (please specify)

Question Title

* 7. Do you want to apply for a tribal travel and lodging scholarship?

Yes

Any comments

Question Title

* 8. Any Questions or Comments?

For Hotel Reservations: Room Block "Tribal Tobacco Prevention"
Hotel: Clearwater Casino & Hotel
15347 Suquamish Way NE
Suquamish, WA 98392
Phone: 360-598-8700
Room Block Rates: + tax

$134 - Resort water-view (double queen or queen breakout room with Murphy bed)
$119 - Resort non-view kings
$111 - Tower non-view (king or double queen)
$126 - Tower northwest-view (king or double queen)
$145 - Tower suites

Hotel Website

Notes from the hotel for online reservations:
Go online to www.clearwatercasino.com, click on Stay & Play for reservations, click on Groups and use the Group ID 13070 to be added.
The cut-off date for reserving a room is 4/27/18.

Northwest Tribal Tobacco Summit - Culture as Prevention Date: Tuesday, May 22, 2018 and Wednesday, May 23, 2018 Time: 8:30am to 5:00pm Location: Kiana Lodge 14976 NE Sandy Hook Rd. Poulsbo, WA 98370 Meeting Location Phone: 866-738-4307 Registration Deadline: May 11, 2018

Question Title

* 1. Contact Information

Question Title

* 2. Does your tribe have a policy in place addresssing:

Question Title

* 3. Would you be willing to share your tribal policies?

Question Title

* 4. Do you use culture in your tobacco program?

Question Title

* 5. If your tobacco program incorporates culture would you be willing to share as part of a group panel?

Question Title

* 6. Do you have any dietary considerations?

Question Title

* 7. Do you want to apply for a tribal travel and lodging scholarship?

Question Title

* 8. Any Questions or Comments?

Northwest Tribal Tobacco Summit - Culture as Prevention
Date: Tuesday, May 22, 2018 and Wednesday, May 23, 2018
Time: 8:30am to 5:00pm
Location: Kiana Lodge

14976 NE Sandy Hook Rd.

Poulsbo, WA 98370

Meeting Location Phone: 866-738-4307

Registration Deadline: May 11, 2018