The Lac qui Parle Health Network is three independent rural health care facilities collaborating to ensure coverage of quality healthcare for your region
Behavioral Health Collaborative
registration & disclaimer
Indicates required field
The undersigned recognizes, as with any activity, there is
of injury. The Undersigned releases the Lac qui Parle Health Network, event sponsors, its employees, agents, and assigns, from any claims including, but not limited to, personal injuries or damage to property caused by or having any relation to this activity. It
that this release applies to any present or future injuries and that it binds the Undersigned, Undersigned’s spouse, heirs, executors and administrators. The Program Participant may be photographed and videotaped while participating in activities, and consent
for the reproduction of such photos or videos for advertising and publicity.
Cost is $10.00
(Upon completion of registration form, you will be linked to Paypal to finalize the registration)
I have read this release and understand all of its terms. I agree with its terms and sign voluntarily.
Bernice Robinson - LqPHN Executive Director
900 Second Avenue
Madison, MN 56256
320-698-7199 ext. 7110