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Citxw Nlaka'pamux Assembly

Health & Wellness Conference

May 4th & 5th

Merritt Civic Centre

Registration Form

Please note, all questions marked with an asterisk(*) are mandatory.

* First Name:

* Last Name:

* Address

* Town/City:

* Postal Code

* Email:

* Phone:

* Band/Community:

* Media Waiver/Release Form: (Please check the box to indicate you have read the waiver form)

The Citxw Nlaka’pamux Assembly (“CNA”), Nlaka’pamux Health Services (“NHS”), Scw'exmx Child & Family Services Society (“SCFSS”), First Nations’ Health Authority (“FNHA”) is seeking your consent to collect, keep, use and share photographs, videos, images, and/or names of participants in the Health & Wellness Conference, Events and Gatherings.

Such purposes may include using them in publications, posters, its internet website or other media, for promotional, social, recreational, cultural, educational, research, commercial, good will and archival purposes.

I understand that my image could possibly be seen worldwide. I agree not to sue the CNA, NHS, SCFSS or FNHA or its employees, directors, officers, or bring claims or demands of any nature against any of them in connection with any matters referred to in this Media Consent including, the use, reproduction or release of my image.

I also agree to the inclusion of my name in connection with any of the matters referred to herein.

Personal Information will be treated as confidential, subject to legislative requirements.

CNA PRIVACY POLICY

* I GIVE MY CONSENT/DO NOT GIVE MY CONSENT for the CNA & SCFSS to collect, keep, use and share my name and/or image for purposes consistent with the above. I understand that images and information posted on the internet may be accessed outside of Canada.