Chickasaw Nation Toksali SMART Participant Consent
By initialing below, I understand and agree to the following:
I understand I am required to follow the approved dress code established by the Chickasaw Nation/Toksali
SMART
program.
I agree to act in a professional manner at all times in accordance with the policies and procedures of the
Chickasaw
Nation Toksali SMART program, both during training sessions and while performing my duties at my
on-the-job training site.
I agree to attend and participate in Toksali SMART program activities. (Training sessions are required and will
be
my assigned on-the-job training site for the day.)
Photograph consent and release:
I hereby grant the Chickasaw Nation, its agents and others working for it or on its behalf and their respective
licensees,
successors and assigns (herein referred to as the “tribe”) the absolute right and permission to use,
publish, reproduce, broadcast and copyright my name, picture, likeness or any material based upon or derived
therefrom, or to refrain from doing, in any manner or media whatsoever for purposes of advertising or trade in
promoting and publicizing the tribe. I agree that my picture or likeness or anything derived therefrom created by the
tribe is owned by it.
Drug testing:
I understand that when I participate in the Toksali SMART program, I may be subject to drug and alcohol testing.
I
understand if I refuse testing; my refusal will automatically result in a positive test.
I give my consent to undergo testing for the presence of illicit drugs and alcohol in accordance with the Chickasaw
Nation’s drug testing policy.
Parental consent/ liability release:
I, , parent/legal guardian of , give my consent for
participation and transportation of my child to all Chickasaw Nation Toksali SMART program events and activities,
including tutoring, if applicable to my child.
I also consent to transporting and emergency treatment, for my child, including decisions regarding the welfare of the program
participant, such as medications and health assessments, up to and including mental and behavioral health care if necessary,
while he is participating in the Toksali SMART program.
I, the undersigned parent/legal guardian of , a minor, do hereby release the Chickasaw
Nation
and its staff or employees of any liability in the event of accidental injury, illness or death to the above-mentioned
minor, while he participates.
I also grant the Chickasaw Nation, its agents and others working for it or on its behalf and their respective licensees,
successors and assigns (herein referred to as the “tribe”) the absolute right and permission to use, publish, reproduce,
broadcast and copyright my name, picture, likeness or any material based upon or derived therefrom, or to refrain from doing,
in any manner or media whatsoever for purposes of advertising or trade in promoting and publicizing the tribe. I agree that
my picture or likeness or anything derived therefrom created by the tribe is owned by it.
If the participant is a minor, a parent or legal guardian shall sign the following space below after reading and agreeing to
the “Liability Release”.
Certification: I certify that the information provided is true and correct to the best of my knowledge. I understand that all
information provided is subject to review and verification, and I may have to provide documents to support this application.
I allow release of this information for verification purposes and understand that it will be used to determine eligibility.
Applicant’s signature Date
Parent/legal guardian signature (if applicable) Date
Emergency contact: Relation to applicant:
Phone: ( ) ____
Page 1 of 1 Form no. 04240-2019 CS-CEA Rev. 11/2020
