QUEST Talk: Belonging Registration

Fill out the form below and click "Submit" to register for "QUEST Talk: BELONGING" on August 4. All youth must be pre-registered to attend. Parents are required to attend the conversation with your teens at the beginning of the evening.

*Required fields

Name*

Age

Address*

City/State/Zip*

Phone*

Email*

Do you need to borrow a sleeping bag?
YesNo

Additional message:

Waiver of Liability and Release

While the staff of the Sacred Pipe Resource Center strives to maintain a safe and healthy environment for all participants, occasional injuries or illnesses require medical attention. We are asking you to sign the permission form below so that we may provide the best possible care for your son/daughter:

I have given my child permission to participate in the SPRC event, and I certify that he/she is in good health and can take part in any physical activities. If an injury occurs and I am not available to give such consent, I authorize the SPRC staff members/volunteers to take all proper action and use the emergency service available at the nearest hospital if necessary. I understand my personal insurance will be used in this case. In case of an emergency, I authorize the personnel to take action. I hereby release, hold harmless, discharge and agree not to take any legal action against Sacred Pipe Resource Center, its directors, officers, employees, volunteers, agents, sponsors, advertisers, owners/leasers of premises for all liability from my child’s participation in these activities.

I also understand and agree that Sacred Pipe Resource Center retains the right to use for publicity and advertising, photographs and video taken of the participants.

I agree to the terms of the Waiver of Liability and Release

Parent/Legal Guardian Name*

Date

[recaptcha]

QUEST Talks

QUEST Talk: BELONGING with Dr. Jason Sole
Friday, August 4, 2017
6:00 pm - 9:00 am

QUEST Talk: INVOLVEMENT with Mark Trahant
Friday, August 18, 2017
6:00 pm - 9:00 am