Mind Over Miles Program 2026 Survey

1.First Name(Required.)

2.Last Name (Required.)

3.Age(Required.)

4.Gender?(Required.)

Male

Female

Other

5.Phone Number(Required.)

6.How often do you run a week, now?(Required.)

7.What size sweatshirt do you wear?(Required.)

9.Emergency Contact Information(Required.)

Name

Phone Number

Media Release
By signing below I authorize the organization identified above to photograph/video myself, my family and any work performed during the FDIHB, Inc. Activity/Event. I understand the photos will be used for informational and instructional purposes only and will not be used to generate a profit or for any commercial purposes. I understand the photos may be used throughout the country by other local, state, and federal agencies for informational and instructional purposes.

Waiver of Liability
In consideration of acceptance of this entry, for myself or administrators, I hereby waive and release any and all rights and claims for damage I may have against Fort Defiance Indian Hospital Board, Inc. and other sponsoring agents or representatives for any and all injuries sustained in any activities, including transportation to and from the site of such activity, related directly or indirectly to my participation in said activity. Refusal to consent will not in any way affect eligibility or access to health care.

10.Signature of Participant(Required.)

Mind Over Miles Program 2026

Mind over miles is a 12-week programs designed to help jumpstart your running quest. We will meet every Monday and Wednesday at 6:00pm to 7:00pm in Sanders, AZ. The program will begin on August 3rd and end on September 23rd.