Page 2 of 2 Form no. 05003A CH-HC Rev. 1/2019
Violation of the Dance Troupe Code of Conduct may result in an individual being deemed
ineligible to participate in dance troupe meetings and events.
Acknowledgements and Attestations
1. I hereby attest that by submitting this application, I have no criminal convictions or history that would
prevent me from having direct contact with children.
2. I acknowledge that cultural resources may conduct a background check on me at any time.
3. I acknowledge that as a member of the dance troupe I may be photographed, recorded, filmed
and/or videotaped. I acknowledge that such photograph, record, film, video may be used in the
future promotion of the dance troupe or by any publication of the Chickasaw Nation. I hereby grant
my permission for such use. I understand that by granting my permission I will not have rights to
approve any such image, video or recording. Further, I will not be due any additional compensation
for the use of such image, video or recording. I will not be entitled to any other claims arising out of
any uses of said image, video or recording.
4. I will hold harmless the Chickasaw Nation, its affiliates, officers, employees, representatives and
assigns from any and all liability, claims, suits, demands, losses, damages caused by or arising out
of or resulting from my participation in dance troupe activities.
5. I understand and acknowledge that as a member of the dance troupe, I am an ambassador of the
Chickasaw Nation. As such, I am bound by the code of conduct located on Page 1 of this
document. I understand and acknowledge that my failure to abide by the code of conduct could
result in my ineligibility to participate in the dance troupe or my dismissal from the dance troupe.
Signed on this day of , 20 .
Print dance troupe applicant’s name
Signature of dance troupe applicant
