Teepee Summit Registration Form Teepee Summit Registration Youth’s Name * Youth's Name First First Last Last Treaty Area * Treaty 6 Treaty 7 Treaty 8 OtherOther Nation/Indigenous Community * Treaty Number – Optional Date of Birth * Address * City * Postal Code * Phone * Email * Emergency Contact * Relationship to youth * Phone * Photograph/Image Consent Form I hereby grant permission to First Nations Health Consortium Ltd. And its representatives to: Photograph and video me and otherwise capture my images and to make recordings of our voices. To reproduce, use, exhibit, display, broadcast and distribute these images and recordings in any media now known or later developed for promoting, publicizing, or explaining First Nations Health Consortium and its activities, and for its administrative, educational or research purposes; and To disclose my dependent(s) identity in relation to any images or recordings taken hereunder. I am the parent or guardian of the dependent(s) noted below, such dependent(s) being under the age of 18 years and/or dependent adult, or youth above 17 years of age and I am duly authorized to provide this consent in my personal capacity and on behalf of each of my dependent(s). Youth’s Name * Youth's Name First First Last Last Do you consent? Yes, I do consent.No, I do not consent. Parent/Guardian’s Name (If under 18) Parent/Guardian's Name (If under 18) First First Last Last Do you consent? Yes, I do consent. Captcha If you are human, leave this field blank. Submit
