Form no. 04022 CS-CSS 11/2016
the
Chickasaw Nation
Environmental Services Area
Chickasaw Nation Environmental Services Area
Parental Consent/Liability Release and Photograph Consent and Release
Event name:
Event location (including city/state):
Event dates (beginning/ending):
Participant name:
Part I: Environmental services area’s staff has my permission (please initial each item signifying your
understanding and agreement):
_____ For my child to participate in the above-mentioned event.
_____ To transport my child for emergency treatment.
_____ To make decisions regarding the welfare of my child, such as medication needs and health
assessments, if necessary, while he/she is participating in this event.
_____ To allow a Chickasaw Nation CHR to conduct health assessments (blood sugar test, hearing test, eye
exam, etc.). I understand he/she will be referred for a follow-up with his/her physician, if applicable.
_____ To administer over-the-counter medications to my child, as needed (ex: acetaminophen, ibuprofen),
except for the following:
Please list any over-the-counter medications your child cannot take
Please list any existing medical conditions your child has of which environmental service area’s staff should be
aware:
Emergency contact name Emergency contact phone no.
Part II: Please initial each item signifying your understanding and agreement:
_____ I hereby grant the Chickasaw Nation, its employees, agents and others working for it or on its behalf
and their respective successors and assigns the absolute right and permission to use, publish,
reproduce, broadcast and copyright my name, picture, likeness or any material based upon or derived
therefrom, in any manner or media whatsoever for purposes of advertising or trade in promoting and
publicizing the Chickasaw Nation.
_____ I agree that my picture or likeness or anything derived therefrom created by the Chickasaw Nation is
owned by the Chickasaw Nation. If I should receive any print, negative or other copy, I shall not
authorize its use by anyone else.
_____ 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 use,
alteration, distortion or illusionary effect in any composite form.
_____ I agree that this release does not in any way conflict with any existing commitment on my part.
_____ I release the Chickasaw Nation and any of its staff or employees of any liability in the event of
accidental injury, illness or death to the above-mentioned child, during the term of this event.
________________________________ __________________________________ _________________
Parent/legal guardian name (print) Parent/legal guardian signature Date
(participants 18 or older may sign form)
Nothing contained herein shall be construed to waive the sovereign rights of the Chickasaw Nation, its officers, employees or agents.
Governor
