STUDENT MINE SUMMIT REGISTRATION
April 27-29, 2001, Mole Lake Sokaogon Chippewa Community

Day you arrive at Summit (circle one):      Friday      Saturday      Sunday
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.

SIGNATURE: _________________________________________________________
Today's date:: April _______, 2001
If under 18: Teacher/chaperone: _________________________________________
Chaperone signature: ______________________________________________________

Wolf Watershed Educational Project c/o Midwest Treaty Network,
731 State St, Madison, WI 53703
(715) 295-9997, (608) 246-2256, (715) 675-8642.