STUDENT MINE SUMMIT REGISTRATION
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| NAME(please print): | __________________________________________________________ |
| Address: | __________________________________________________________ |
| Town/ZIP/State: | __________________________________________________________ |
| School and year: | __________________________________________________________ |
| Group (if any): | __________________________________________________________ |
| Age: | __________ |
| Home phone: | ( ) _______________________________ |
| E-mail (if any): | __________________________________________________________ |
| Emergency contact: | __________________________________________________________ |
| Contact phone: | ( ) _______________________________ |
| Do you have any serious medical problems? (if yes, please specify:) | |
| _______________________________________________________________________ | |
| Are you on medication? (if yes, please specify:) | |
| _______________________________________________________________________ | |
| Any severe allergies? ______________________________________________________ | |
| Any foods you cannot eat? __________________________________________________ | |
I, my heirs, assigned representatives, executors or administrators, hereby release from and promise to hold harmless of any bodily or mental harm, injury, loss, illness, or death, the Mole Lake Sokaogon Chippewa Community, Midwest Treaty Network, Wolf Watershed Educational Project, and their officers and members, member groups, employees, advisors, agents or representatives, that may result in my participation in the Student Mine Summit or travel to and from the event. I have read the foregoing and sign this of my own free will without any coercion of duress. |
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| SIGNATURE: | _________________________________________________________ |
| Today's date:: | April _______, 2001 |
| If under 18: | Teacher/chaperone: _________________________________________ |
| Chaperone signature: ______________________________________________________ | |
| 731 State St, Madison, WI 53703 (715) 295-9997, (608) 246-2256, (715) 675-8642. |
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