2024 Spring Into Summer Hiking Series

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Event Timing: May through September
Event Address: Trails in the Flagstaff Area
Contact us at (928)773-1245, ext. 221 or email at hpwc@nacainc.org

NOTE: Please complete a registration form for every adult. Participants must provide their own transportation.

Trail Information and Hike Updates will be sent the week before to the email provided. PLEASE ARRIVE AT LEAST 30 MINUTES PRIOR TO THE START OF THE HIKE (7am).

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First and Last Name *

Email *

Date of Birth *

JJJJ

Ethnicity *

Gender *

Phone Number *

Address (City, State, Zip Code) *

Emergency Contact- Name (Relationship) and Phone Number
*

Attending Minors- If under the age of 18, Parent/Guardian must sign. Insert Names, Date of Birth and Relationship of Child(s) below. IF NO CHILD, INSERT N/A.
*

Are you a NACA Patient?
*

Yes

Sonstiges:

Would you like to be contacted regarding future NACA Health Promotion Events?
*

Yes

Sonstiges:

Do you have a history of any of the following:
*

Pre- Diabetes

Type 2 Diabetes

Hypertension (Elevated Blood Pressure)

Obesity

Would you like to be contacted for more information on Health Promotion services related to your health history?

Sonstiges:

Pflichtfrage

How Did You Hear about our Event? Please check one box.
*

Word of Mouth

Facebook

NACA Facility Advertisement

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PARTICIPANT WAIVER AND RELEASE: Each participant (hereafter referred to as “Participant”) listed on the form above, intending to be legally bound, herby certifies that he/she is physically fit and in normal health and has not been otherwise informed by a physician that he/she is incapable of participation in any community events sponsored by the NACA Health Promotion Program. Each participant agrees to abide by all NACA Health Promotion Program event rules. Each participant acknowledges that he/she is aware of the risks inherent in participation in NACA Health Promotion Program events; that events may be physical and can require considerable running, starting, stopping, and physical exertion, in heat and humidity, and could potentially lead to injuries including, but not limited to, overheating, dehydration, and injuries; each participant agrees to assume all those risk and to waive any and all rights to claim for injuries, loss or damages arising out in his/her participation in the NACA Health Promotion Program events. Each participant is responsible of conducting him/herself and at a level consistent with his/her fitness level. This form also serves as a release of any and all rights/claims for damages against the NACA Health Promotion Program, Native Americans for Community Action, Inc., and other community partner organizations/representatives. Each participant further certifies that he/she maintains adequate health insurance to cover any injuries occurring as a result of participation in events with the NACA Health Promotion Program. If, while participating in any NACA Health Promotion Program event, a participant hurts another person or damages property of another individual, he/she will be held responsible for said actions.

Upon submission, I hereby release and agree to hold NACA Wellness Center harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of NACA Wellness Center, or that may otherwise arise in any way in connection with any services received from NACA Wellness Center. I understand that this release discharges NACA Wellness Center from any liability or claim that I, my heirs, or any personal representatives may have against NACA Wellness Center with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from NACA Wellness Center. This liability waiver and release extends to NACA Wellness Center with all owners, partners, and employees. By agreeing below, participant acknowledges understanding and reading of this waiver in full.

I Agree to the Above Statement

I Disagree to the Above Statement

DISCLAIMER NOTICE: I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that NACA Wellness Center has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that NACA Wellness Center cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, NACA Wellness Center staff, and other NACA Wellness Center clients/participants and their families. I voluntarily seek services provided by NACA Wellness Center and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending this event. I attest that:
*

I am not experiencing any symptoms of illness such as couch, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chillls, muscle pain, headache, sore throat, or new loss of taste or smell.

I have not traveled internationally within the last 14 days.

I have not traveled to a highly impacted area within the United States of America in the last 14 days.

I do not believe I have been exposed to someone with suspected and/or confirmed case of the Coronavirus/COVID-19.

I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.

I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

Pflichtfrage

The NACA Marketing Officer will be taking photographs at the event. These photos will only be used for NACA Marketing purposes. If you do not want to be included in any photographs, please let us know below. Do you give consent for NACA to use your likeness in photographic marketing material? *

Yes

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