Page 1 of 3 Form no. 05003M CH-HC Rev. 10/2018
History and Culture Division
867 Charles Cooper Memorial Road / Sulphur, OK 73086 / (580) 622-7140
Chikasha Hilha’ Himitta’ (Chickasaw Young Dancers) Application
Date of application:
Participant’s name:
Last First Middle Suffix
Mailing address:
Street City State ZIP
Physical address:
Same as Mailing Street City State ZIP
Home phone: (_____) Participant’s cell no.: (_____)
Email address:
Birth date: Age: Gender: Male Female
Allergies to medications or food:
Emergency contact name:
Emergency contact phone: (_____)
Please indicate shirt size:
Kid’s Small Medium Large
Youth Small Medium Large
Adult Small Medium Large XL 2XL 3XL
Bill Anoatubby
Governor
Page 2 of 3 Form no. 05003M CH-HC Rev. 10/2018
Code of Conduct
While representing the Chickasaw Nation as a dance troupe member, the undersigned member will abide
by the following standards and rules of conduct:
Dance troupe members shall follow the directions of the cultural resources department designee.
No dance troupe member shall make public or private statements or actions on behalf of the tribe on any matters
concerning the Chickasaw Nation or its programs.
Gossiping is detrimental to all team members and will not be tolerated.
Use of alcohol and drugs is prohibited.
No offensive language or images on clothing.
No smoking in the vehicles.
Derogatory language, harassing and bullying will not be accepted.
Members receiving per diem are required to pay their own meal expenses.
Regalia for performances will be determined by the appropriate delegate based on event.
Members will be dressed and ready to perform in a timely manner. Members will adhere to the itinerary that has
been established by the coordinator.
Dance troupe members will remain respectful of individual and cultural diversity.
Dance troupe members are to conduct themselves in a professional and positive manner at all dance troupe
functions and events.
Members will be on time for event departures.
If members do not follow these guidelines they can be dismissed and will be asked not to attend practices, events
or gatherings.
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 understand that as a member of the dance troupe my child may be photographed, recorded, filmed
and/or videotaped by employees of agents of the Chickasaw Nation for promotion of the dance
troupe or in any publication of the Chickasaw Nation. I hereby grant my permission for such use on
behalf of my child. I understand that by granting my permission neither I nor my child will have rights
to approve any such image, video or recording. Further, neither I nor my child will not be due any
additional compensation for the use of such image, video or recording. Neither I nor my child will be
entitled to any other claims arising out of any uses of said image, video or recording.
2. I understand that the dance troupe may travel within the state of Oklahoma and out of state.
3. 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
or resulting from my and my child’s participation in dance troupe activities.
4. I understand and acknowledge that as a member of the dance troupe, my child is an ambassador of
the Chickasaw Nation. I understand and acknowledge that my child’s failure to abide by the code of
conduct located on Page 1 of this document could result in his ineligibility to participate in the dance
troupe or his dismissal from the dance troupe.
Signed on this day of , 20 .
Print dance troupe applicant name
Signature of parent/ legal guardian
Page 3 of 3 Form no. 05003M CH-HC Rev. 10/2018
Parent Consent Form
Medical Permission
I am the parent/legal guardian of ____________________________, a minor child. I hereby give my
consent and approve of the participation of my child in the Chickasaw Nation Dance Troupe.
In the event my child should require medical attention, I hereby grant my permission to the Chickasaw
Nation Cultural Resources employees to seek medical attention for my child and consent to my child
receiving medical attention during any event in which the troupe is participating. I acknowledge that the
Chickasaw Nation, its employees, associates, or agents are not liable for any act leading up to, or
arising from such an event.
Signature of parent/ legal guardian Date Phone
Witness signature Witness printed name
Emergency contact Phone
Current medications (please list):
Known allergies (food, medication, latex, etc.) (please list):