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NAME:
DATE OF BIRTH:

ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER:
EMAIL:

GENDER:

Oneida Tribal Member:	Enrollment #:
Other Tribal Affiliation:	Tribe:
Oneida Tribe Employee:	ID #:
Oneida Tribe Employee Family Member:

In a typical week, how many days do you do at least 30 minutes of
physical activity?

On a typical day, how many FRUITS & VEGETABLES do you eat?

On a typical day, how many cans of REGULAR POP or SWEETENED
FRUIT DRINKS do you drink? (44 oz. = 3-1/2 cans)

On a typical day, how many hours do you watch TV, play VIDEO
GAMES, or use the COMPUTER? (Do not include work or school hours)

JMIO Events:

T-Shirt Size:

By typing your name in full below, you are acknowledging that you are the signer for this participation agreement. If the person listed in the Participant Information section is a minor, a parent or guardian must sign this document for the individual to participate in the Just Move It Oneida events selected.

Full Name of Signer:

By checking Yes, I am the parent and/or legal guardian of the minor identified in the Participant Information section of this registration.

WAIVER OF RESPONSIBILITY: In consideration of your acceptance of this entry, for myself, heirs, executors, or administrators, I hereby waive and release any and all rights and claims for damage I may have against sponsoring
organizations or representatives for any and all injuries sustained by in any activity, including transportation to and from the site of such activity, related directly or indirectly to my participation of said activity. I hereby give my
permission for the use and reproduction of video footage, photographs or audio recordings. I understand that any use of my image and/or voice will be for the purpose of health promotion.

Just Move It Oneida is coordinated by Oneida Health Promotion/Disease Prevention of the Oneida Comprehensive Health Division.
OP 21703 R12/14

For questions & comments, contact Hanna Leisgang (920) 490-3927/hleisgan@oneidanation.org

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Just Move It Oneida - Event Registration Document

Unique Document ID: 6042e82e7166ddce860367c65ec4b2a2c3b1a267

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January 13, 2021 3:00 pm CDT

Just Move It Oneida - Event Registration Document Uploaded by Oneida Nation - webmaster@oneidanation.org IP 74.62.93.28:24580

January 13, 2021 3:04 pm CDT