S.A.G.E. Project Registration

The SAGE Project is funded by the Center for Disease Control and Prevention (CDC). The goal of this grant is to look at the traditional activities that kept our communities healthy and use the knowledge of our elders to implement those practices to create a healthier future. Please fill out the following form to stay updated on all the S.A.G.E. Project programming and events. Thank you for your time and response.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Date of Birth*

Date

Do you identify as American Indian?*

YesNo

If you do identify at American Indian, what tribe?

PERMISSION TO PHOTOGRAPH/VIDEO AND PUBLICIZE

I hereby give permission to the American Indian Clubhouse to photograph myself at United American Indian Involvement, Inc. (UAII) events. I understand that photographs or videos of myself may appear in newspapers, magazines, television, video presentations, UAII publications, website, and social media applications. I agree that I will not demand payment of any kind in the event that my picture, video, voice, likeness, drawings or writings are used by UAII to promote or publicize any of its programs or activities.

Do you give permission?*

YesNo

WAIVER OF LIABILITY, ASSUMPTION OF RISK, & INDEMNITY AGREEMENT WAIVER

In consideration of being permitted to participate in the S.A.G.E. Project activities hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue United American Indian Involvement, Inc, its officers, employees, and agents, and the American Indian Clubhouse, from liability from any and all claims including the negligence of United American Indian Involvement, Inc, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD United American Indian Involvement, Inc and the American Indian Clubhouse HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement fully, understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Signature*

Today's Date*

Date