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N a m e : T r ibe/Organi z a t i o n :

Nike Native Fitness Training Registration Form Haskell Health Center. A u g u s t 3 & 4 , 2 01 1 Nike Wo r ld H ea d q u a r te rs , Bea v erton , O r egon Native Fi t nes s V I II Regist r atio n Fo r m.

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N a m e : T r ibe/Organi z a t i o n :

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  1. Nike Native Fitness Training Registration Form Haskell Health Center August 3& 4,2011 NikeWorldHeadquarters,Beaverton, Oregon NativeFitnessVIIIRegistration Form • ConferenceRegistrationDeadline: First175 participantswill beaccepted • Please submit one registrationformforeachparticipant • Firsttimeattendeeswill begivenpreference • Registration islimited to(3)staffperTribe,Organization,orArea • Please coordinate withyourDiabetesprogram • Participant attendance ismandatory forentirelengthofevent • Thistraining isonly opento those 18years of ageandolder • EachparticipantwillreceiveonepairofNikeAthleticShoes • Please noteparticipantsnameon registrationpayments • Prepaymentis required,paymentwill notbeacceptedon site • No exchanges or refundsforconference registration orproducts HostHotel: HomewoodSuites15525NWGateway Ct. Beaverton, Oregon Phone(503)614-0900 PleaseReference: “The Native Fitness Training”whenbooking your room,inordertoreceivethegrouprate of$139.00 +taxpernight.Participants are responsiblefortheirown traveland lodging costs. Allreservationsmadeby individuals are considereddefinite oncutoff dateof 7/9/11, any reductionof roomnights orcancelled roomsafterthecutoffdate will be charged. Hotel Reservation Deadline July9, 2011 By completingthisregistrationform, youareauthorizing the NorthwestPortland Area IndianHealthBoard,aswellitscollaboratingpartners to utilizeany photographic images takenatthe conference to be used forpromotional purposes. Name:Tribe/Organization: Title:Email:Phone:Fax:Address:City:State:Zip:RegistrationFee:$175.00 ShoeType/CircleOne: N7AirNative / Pegasus (shoebrandnotguaranteed) Check/Purchase Order#: Shoe Size: CircleOne:Men’s/Women’s Fax/Mail Registrationand Payment to: WesternTribalDiabetesProject/NPAIHB, 2121SW Broadway Suite300,Portland,OR 97201CasandraBelgard,Email: cbelgard@npaihb.org (503)416-3289, Fax(503)228-4801 Thistraining includesphysicalactivitysoremember towearyourNIKEworkoutattire!

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