Fillable Chikasha Toli Registration Form (The Chickasaw Nation)

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Chikasha Toli Registration Form (The Chickasaw Nation)

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Form no. 05001CT CH-HC Rev. 4/2018
Chikasha Toli’
Registration Form
Contact information:
Name:
First Middle Last Suffix
Birth date: Age: Gender: □ Male ☐ Female
Phone number: ( ) Text: ☐ Yes ☐ No
Email: Alternate phone number: ( )
Address information:
Mailing address:
Street City State ZIP
Physical address:
Street City State ZIP
Region (Please check one): ☐ Ada ☐ Norman ☐ Sulphur ☐ Tishomingo
Parental information (If player under 18):
Parent/legal guardian name: Place of work:
Phone number: ( ) Email:
Parent/legal guardian signature:
Emergency contact:
Name:
Phone number: ( ) Alternate phone number: ( )
Shirt size (Please check one):
☐ S ☐ M ☐ L ☐ XL ☐ 2XL ☐ 3XL ☐ 4XL
Questions/contact: (580) 436-7258
Brandon.Whiteeagle@chickasaw.net
Department of Culture and Humanities / History and Culture Division
Bill Anoatubby
Governor
Form no. 05001CT CH-HC Rev. 4/2018
“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.
Emergency contact information (name):
Address City State ZIP
Emergency contact phone number: ( )
Signature of participant Date
Signature of parent/legal guardian (if participant is under the age of 18) Date
Witness signature Date
Title
Form no. 05001CT CH-HC Rev. 4/2018
Chikasha Toli’
Code of Conduct
While representing the Chickasaw Nation as a Chikasha Toli’ stickball member, the
undersigned member will abide by the following standards and rules of conduct:
Chikasha Toli’ members will follow the directions of the history and culture
division designee.
No Chikasha Toli’ member will make public or private statements or actions on
behalf of the tribe on any matters concerning the Chickasaw Nation and its
programs.
Gossiping is detrimental to all team members and will not be tolerated.
Use of alcohol and drugs are prohibited.
No offensive language or images on clothing.
No smoking in the tribal vehicles.
Derogatory language, harassing and bullying will not be accepted.
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.
Chikasha Toli’ members represent the tribe at all times and will act appropriate.
Violation of the Chikasha Toli’ Stickball Code of Conduct may result in an individual
being deemed ineligible to be a member for the Chikasha Toli’ stickball team.
Member signature Date
Department of Culture and Humanities / History and Culture Division
Bill Anoatubby
Governor
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Chikasha Toli Registration Form (The Chickasaw Nation)

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Completed 31 January 2021

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