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