ONAC of ICSAW Membership & Release Form INTERNATIONAL CENTER OF SPIRITUAL AND ANCESTRAL WISDOM (ICSAW) AN INDEPENDENT BRANCH OF OKLEVUEHA LAKOTA SIOUX NATION NATIVE AMERICAN CHURCH OF UTAH INC. (ONAC) A NON-PROFIT RELIGIOUS CORPORATION 1353164-0140 Complete form online or download, print it, fill out & mail/email to us at firstname.lastname@example.org. Download PDF ONAC OF ICSAW Membership & Release FormThis document is to acknowledge that the undersigned is an authorized Participant of ONAC of ICSAW. As an authorized Participant, the undersigned is authorized to participate in Native American Church ceremonies and activities under the following terms and conditions: 1. I agree to participate in ONAC OF ICSAW ceremonies of my own free will, choosing and volition. I have been informed of the nature of these ceremonies and activities and do state affirmatively that I have in no way been coerced or manipulated in any manner by any representative of ONAC OF ICSAW. 2. I agree not to leave any ONAC OF ICSAW ceremonies and activities before the completion of the event. I understand that if I choose to leave any ONAC OF ICSAW activities before its completion, I do so at my own risk. 3. I confirm that I have no medical, emotional, psychological condition that would put me at risk in participating in ONAC OF ICSAW. 4. I have received and read copies of ONAC of ICSAW’s Code of Conduct, Code of Ethics, and Standards and Principles and agree to abide by all of them to stay a member in good standing. I, the undersigned, hereby verify that I have read, do understand, and do agree to all above terms and conditions and do willingly participate in ONAC OF ICSAW ceremonies, Classes and any or all Church activities of my own free will and volition.Name* First Last Type your name here to agree with the above terms & conditions and sign electronically. Today's Date* Date Format: MM slash DD slash YYYY Medical Information/Release:We ask for this information so we could know in advance of special medical conditions you may have, rather than learning about them during the ceremonies, classes and events. For your safety we will review this form, and the leader may contact you to discuss whether the events will be good and enjoyable for you considering your medical history. We will keep the information on this form confidential. Only the organizers and / or others who know and understand its confidential nature will see it. The form will be retained along with your liability waiver for a period of time following the meetings, after which it will be destroyed. If you choose not to go to the ceremonies, this form will be destroyed immediately.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter Email Confirm Email Phone*Date of Birth* Date Format: MM slash DD slash YYYY Emergency Contact Name* First Last Relationship to Emergency Contact*Emergency Contact Phone*Are you a tribal member?*NoYesTribal Number*Are you a veteran?*NoYesMedical HistoryPlease list all prescription, over-the-counter, and natural medications you are taking or write none.*Do you use Antidepressants, steroids antihypertensive medications?*NoYesPlease list what you are taking:*Medical ConditionsHave you had a recent illness (in the last year)?* No Yes Recent Accidents?* No Yes Surgical Operations?* No Yes Explain or elaborate on any illnesses, accidents or surgical operations in the last year:*Hospitalizations?* No Yes Do you have asthma?* No Yes Do you have diabetes?* No Yes Explain or elavorate on anything related to your hospitalizations, asthma or diabetes:*Do you have high blood pressure?* No Yes History of cardiac failure or stoke?* No Yes Are you pregnant?* No Yes Explain or elavorate on anything related to your high blood pressure, history of cardiac failure or stroke, or your pregnancy::*Bone, joint, or muscle problems?* No Yes Have you ever had a seizure?* No Yes Do you have any history of mental illness?* No Yes Explain or elavorate on anything related to your bone, joint or muscle problems, history of seizure, or mental illness::*Ever hospitalized for emotional reasons?* No Yes Do you have any other medical issues that might affect your participation in this ceremony?* No Yes If you have no such limitations, please initial here:Explain or elavorate on anything related to your hospitalization for emotional reasons or any other physical or mental limitations or restrictions that you are aware of:*Liability Release:In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event’s leader, organizers and participants from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted. To the best of my knowledge, I am in good physical condition and I am not aware of any physical and/or psychological infirmity, which would place me at risk to participate in any way with the ceremony activities. I am fully aware of the risks and hazards connected with this event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. In signing this release, I acknowledge and represent that I have read and understand it and sign it voluntarily.Name* First Last Type your name here to agree with the above terms & conditions and sign electronically. Today's Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.