Oneida Nation | JMIO Event Registration

Participant Information

First Name *

Middle Initial

Last Name *

Date of Birth *

Contact Information

Address

City

State

Zip

Phone

Email *

Additional Information

Gender Gender

Are you a Oneida Tribal Member? *

Yes

No

What's your enrollment number?

Are you affiliated with another tribe?

Yes

No

Which tribe?

Are you an Oneida employee? *

Yes

No

What is your employee number?

Are you an Oneida employee's spouse or child?

No

Yes, spouse

Yes, child

In a typical week, how many days do you do at least 30 minutes of physical activity?

On a typical day, how many FRUITS & VEGETABLES do you eat?

On a typical day, how many cans of REGULAR POP or SWEETENED FRUIT DRINKS do you drink? (44oz = 3.5 cans)

On a typical day, how many hours do you watch TV, play VIDEO GAMES, or use the COMPUTER? (Do not include work or school hours)

T-Shirt Size *

By typing your name in full below, you are acknowledging that you are the signer for this participation agreement. If the person listed in the Participant Information section is a minor, a parent or guardian must sign this document for the individual to participate in the Just Move It Oneida events selected.

Full Name of Signer *

By checking Yes, I am the parent and/or legal guardian of the minor identified in the Participant Information section of this registration.

Yes

WAIVER OF RESPONSIBILITY: In consideration of your acceptance of this entry, for myself, heirs, executors, or administrators, I hereby waive and release any and all rights and claims for damage I may have against sponsoring organizations or representatives for any and all injuries sustained by in any activity, including transportation to and from the site of such activity, related directly or indirectly to my participation of said activity. I hereby give my permission for the use and reproduction of video footage, photographs or audio recordings. I understand that any use of my image and/or voice will be for the purpose of health promotion.

Just Move It Oneida is coordinated by Oneida Health Promotion/Disease Prevention of the Oneida Comprehensive Health Division.
OP 21703 R12/14

For questions & comments, contact Hanna Leisgang (920) 490-3927/hleisgan@oneidanation.org