Community Health Representatives

Improving Health & Safety

The Osage Nation Health System Community Health Representatives (CHRs) program is dedicated to promoting a superior standard of community health, our initiative focuses on delivering top-notch health prevention, education, and information. By elevating awareness and advocating for healthier lifestyles, we aim to positively impact the well-being of Osage Nation community members.

2026 CHR Summer Swim Registration & Waiver below

ONHS Community Health Reprtesentatives Summer Swim Initiative 2026

The CHR Program sponsors a Summer Swim Initiative for Osage and federally recognized Native Americans living in Osage County. This event is intended to encourage health promotion and disease prevention by swimming at the community pools in Fairfax, Hominy, and Pawhuska through the summer season. To participate, parents or guardians must complete the form for each participant, provide a copy of their tribal membership or CDIB card and proof of address. If person signing up participant is not a parent, please provide proof of legal guardianship with this registration form. Registration guidelines and requirements: * Registration must be completed by a parent or legal guardian. * A maximum of four (4) children may be registered per form. * If registering five (5) or more children, an additional registration form must be submitted. * A liability waiver acknowledgment is required at the end of this form to complete registration. *Required documents include: -Tribal enrollment cards/verification for all individuals listed on registration form -Proof of address -Guardianship documentation for all minor children if guardian is not listed on birth certificate

Name (Parent/Guardian only please)(Required)

First Last

Parent/Guardian Age

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Phone(Required)

Tribal Affiliation(Required)

Which pool location are you requesting summer passes for?(Required)

Are you registering your minor children?(Required)

Yes

Only parents/guardians are permitted to sign up for their children. Four children max can be registered per registration form. If you have five or more children, please complete an additional registration form.

Name (Child 1)(Required)

First Last

Age (Child 1)(Required)

Tribal Affiliation -Child 1(Required)

Add 2nd child?(Required)

Yes

Name (Child 2)(Required)

First Last

Age (Child 2)(Required)

Please enter a number greater than or equal to 0.

Tribal Affiliation -Child 2(Required)

Add 3rd child?(Required)

Yes

Name (Child 3)(Required)

First Last

Age (Child 3)(Required)

Please enter a number greater than or equal to 0.

Tribal Affiliation -Child 3(Required)

Add 4th child?(Required)

Yes

Name (Child 4)(Required)

First Last

Age (Child 4)(Required)

Please enter a number greater than or equal to 0.

Tribal Affiliation -Child 4(Required)

Parent/Guardian Tribal Enrollment Card

Max. file size: 50 MB.

Tribal Enrollment Cards – Child 1(Required)

Max. file size: 50 MB.

Tribal Enrollment Cards – Child 2(Required)

Max. file size: 50 MB.

Tribal Enrollment Cards – Child 3(Required)

Max. file size: 50 MB.

Tribal Enrollment Cards – Child 4(Required)

Max. file size: 50 MB.

Proof of Address(Required)

Max. file size: 50 MB.

Proof of address: Current utility bill or current bill at current address.

Guardianship Documents

Drop files here or

Max. file size: 50 MB.

Proof of Guardianship Documents is required if guardian is not listed on child’s birth certificate. Please provide a copy of any documents applicable to guardianship for children you are signing up.

Additional Documents?(Required)

Yes

Guardianship Documents

Drop files here or

Max. file size: 50 MB.

WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT 1. In consideration for myself and/or my child participating in the Osage Nation Community Health Representative’s Summer Swim 2026 Initiative, I hereby RELEASE, WAIVE, AND DISCHARGE THE OSAGE NATION HEALTH SYSTEM, their officers, agents, volunteers, and employees (hereinafter referred to collectively as the “Osage Nation”) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child or any of the property belonging to me or my child WHETHER CAUSED BY THE NEGLIGENCE OF THE OSAGE NATION HEALTH SYSTEM or otherwise, while participating in the event and associated activities or while in, on, or upon the premises where the event is being conducted. 2. I am fully aware of the risks involved and hazards connected with my and/or my child’s participation in this program and traveling. I hereby elect to allow myself and/or my child to voluntarily participate in said activities of the program with full knowledge that said activities may be hazardous to my child and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH that may be sustained by myself and/or my child, or any loss or damage of property owned by me or my child, as a result of being engaged in such activities WHETHER CAUSED BY THE NEGLIGENCE OF THE OSAGE NATION OR OTHERWISE. 3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE OSAGE NATION from any loss, liability, damage, or cost, including court costs and reasonable attorneys’ fees that the Osage Nation may incur due to my child’s participation in said event associated activities WHETHER CAUSED BY NEGLIGENCE OF THE OSAGE NATION HEALTH SYSTEM or otherwise. 4. I express my intent that this Waiver of Liability and Indemnification Agreement bind me and the members of my family, spouse, and heirs, assignees, and personal representative. It shall be deemed as a complete RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE THE OSAGE NATION HEALTH SYSTEM. BY SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Indemnification Agreement, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement have been made; and I am at least eighteen (18) years of age and/or the Parent or Legal Guardian of the minor participant; if Participant is under the age of eighteen (18) years of age, Parent/Legal Guardian consents to the minor’s participation in the event; consents for the Osage Nation Health System to seek reasonable and necessary medical treatment for their child during such or associated activities; and agrees to be responsible for any cost of such treatment. By my signature below, I acknowledge and execute this agreement for full, adequate, and complete consideration, fully intending to be bound by same.(Required)

I have read, understand, and agree to the Waiver of Liability and Indemnification Agreement. I acknowledge and accept all terms and conditions on behalf of myself and/or my child(ren).

I do not agree to the Waiver of Liability and Indemnification Agreement and understand that I and/or my child(ren) will not be permitted to participate in the event.

Type Name(Required)

I certify that the information provided on this registration form is true and accurate to the best of my knowledge. I understand and agree to comply with all program guidelines and requirements. By signing below, I acknowledge that I have read and accept the terms outlined above.

Improving Health & Safety

ONHS Community Health Reprtesentatives Summer Swim Initiative 2026

Contact Your Community Health Rep