Fillable Chipota Chikashshanompoli: Children Speaking Chickasaw Language Club Youth (The Chickasaw Nation)

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Chipota Chikashshanompoli: Children Speaking Chickasaw Language Club Youth (The Chickasaw Nation)

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Form no. 05002CC CH-HC Rev. 1/2017
Chipota Chikashshanompoli: Children Speaking Chickasaw Language Club
Youth Stickball Team Application
Contact information:
First name: Last name:
Age: ☐ Male ☐ Female
Allergies/health concerns:
Shirt size (Please check one):
☐ YS ☐ YM ☐ YL ☐ S ☐ M ☐ L ☐ XL ☐ 2XL ☐ 3XL ☐ 4XL
Short size (Please check one):
☐ YS ☐ YM ☐ YL ☐ S ☐ M ☐ L ☐ XL ☐ 2XL ☐ 3XL ☐ 4XL
Address information:
Street:
City: State: ZIP:
Parent/guardian information:
Parent/guardian name: Phone:
Text: ☐ Yes ☐ No Email:
How would you like to be kept updated: ☐ Text ☐ Email
Parent/guardian signature:
Emergency contact information:
Name: Phone:
Questions/contact:
Clovis Hamilton: 580-272-5592 or Clovis.Hamilton@chickasaw.net
Bill Anoatubby
Governor
Governor
Form no. 05002CC CH-HC Rev. 1/2017
“The Chickasaw Nation Stickball Activities Waiver, Release of Liability, and
Assumption of Risk and Rule Form”
To participate in the stickball activities sponsored by the Chickasaw Nation Department of Culture and
Humanities, I, the undersigned (print name of participant),
acknowledge, understand and agree to the following:
1. The risk of injury from participating in stickball activities including practice sessions, exhibitions
and games, is significant and has the potential for serious injury and/or even death.
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF
ARISING FROM THE NEGLIGENCE OF THE CHICKASAW NATION, or others, and assume all
and full responsibility for my participation.
3. I willingly agree to comply with the rules and regulations that govern the stickball games and
activities.
4. I, on behalf of myself, my heirs, assigns, personal representatives and next of kin, HEREBY
RELEASE AND HOLD HARMLESS the Chickasaw Nation, its employees, agents and
representatives WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or
damage to person or property, WHETHER ARISING FROM NEGLIGENCE OR OTHERWISE.
5. My permission is granted to the Chickasaw Nation, its agents or employees to photograph,
record, film and videotape me or my child for future promotion of the Chickasaw Nation Department
of Culture and Humanities programs and/or any Chickasaw Nation publications. I shall have no
right of approval, no claim to additional compensation and no claim (including without limitation,
claims based upon invasion of privacy, defamation or right of publicity) arising out of any uses,
alteration, distortion or illusionary effect or use in any composite form.
6. I HAVE READ THIS WAIVER/RELEASE OF LIABILITY/ASSUMPTION OF RISK AND RULES
FORM, AND FULLY UNDERSTAND THAT BY SIGNING THIS FORM, I AM AUTHORIZED OR
HAVE LEGAL AUTHORITY TO CONSENT ON BEHALF OF MYSELF OR THE ABOVE-NAMED
MINOR CHILD.
Signature of participant Date
Signature of parent/guardian (if participant is under the age of 18) Date
Emergency contact information (name):
Address State ZIP Phone
Witnessed by:
Date
Title
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Chipota Chikashshanompoli: Children Speaking Chickasaw Language Club Youth (The Chickasaw Nation)

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Completed 31 January 2021

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