Hosted by the Washoe Tribal Healing Center
Registrants need to be age 18 or over

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* 1. Name (First, Last)

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* 2. Phone number

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* 3. Email

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* 4. Affiliation (please specify)

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* 5. Washoe Community, Tribe, or Entity - ground transportation will be available from the communities, would you like to reserve a spot for transportation?

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* 6. A block of hotel rooms have been reserved at the GSR, please let us know if you would like cost information/block discount code

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* 7. If yes, how many days would you need a hotel room?

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* 8. Do you have any food allergies/restrictions?

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* 9. Media Release

I hereby give the Washoe Tribal Health Center and its fiscal agent, the Washoe Tribe of Nevada & California, permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, texts/letters and the like, taken or made on behalf of the Washoe Tribal Health Center’s or the Washoe Tribe of Nevada & California’s activities. I agree that the Washoe Tribal Health Center have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the Washoe Tribal Health Center’s missions. These uses include, but are not limited to newsletters, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release the WTHC/WTNC and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.

I have read and understood this consent and release.

I give my consent to the WTHC/WTNC to use my name and likeness to promote the WTHC program, its fiscal agent, and/or their activities.

Please electronically sign below if you agree, type your name.
If you do not wish to allow media release, type in "I do not agree."

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