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Turtle Healing Band Membership Agreement
TURTLE HEALING BAND MEMBERSHIP AGREEMENT
Patient Full Name:
(Required)
First
Middle
Last
Country Of Residence:
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone Number:
Add your country code + Full Number Please
Email Address:
example@example.com
Name of Tribal Provider/Facility
(Required)
I do hereby request membership in Turtle Healing Band (“THB”) to be treated as a patient by a Tribal Provider (“TP”) licensed and approved by First Nation Medical Board (“FNMB”). With the signing of this Agreement, I/we agree that all people have a divinely-given right to choose and receive for themselves any type of healing they feel is best for their mind, body and spirit. These options include, but are not limited to, all forms of indigenous medicine (e.g., alternative, complementary, holistic, integrative, etc.) whether traditional or non-traditional, as well as conventional medicine.
In addition, I affirm and understand that: (1) THB members are protected by the First and Fourteenth Amendments to the U.S. Constitution as well as the United Nations General Assembly (Universal Declaration of Human Rights adopted at the Palais de Chailot in Paris on December 10, 1948); (2) THB is outside the jurisdiction and authority of federal, state, county, and city agencies and authorities for any and all complaints or grievances against FNMB, FNMB licensees, FNMB staff, Turtle Healing Band Clinics (“THBC”), and THBC staff; and (3) THB member records are the private property of THBClicensed facilities and are kept confidential.
I also attest that I am here solely on my behalf (and that of my family) and not as an agent or representative for any Federal, State, County, or City Agencies. Further, I/we neither represent any Board (e.g., medical, zoning, etc.) or Licensing Agency (e.g., government, healthcare, etc.) nor am I on a mission of entrapment or investigation on behalf of these or any other agencies, either on this or any subsequent visit(s).
UNDERSTANDING
I (and my family) agree to become a patient(s) and private member(s) of THB so that I/we may be entitled to receive goods and services from a TP providing service in a THBC facility. I further understand that it is entirely my/our own responsibility to consider the advice and recommendations offered to me/us by TPs or our fellow THB members and to educate myself/ourselves as to the possible risks and benefits of such recommendations. I/We agree to hold the tribal practitioners, healers, technicians, staff, and other THB members harmless from unintentional liability resulting from my/our indigenous healthcare, except for harm that results from criminal misconduct or gross negligence as determined by FNMB and/or defined by Crow Tribal Court. I/We agree to submit to the jurisdiction of FNMB for the referral of any and all complaints against TPs to FNMB for dispute resolution. Further, I/We agree to submit any civil complaints against TPs to Crow Tribal Court for dispute resolution.
NOTICE
Notice is hereby given to all persons that they may be in violation of Civil and Constitutional Rights should they receive a copy of this Agreement and then act under the color of law to intentionally interfere with the free exercise of the Rights retained by THB members under the Ninth Amendment (see Title 42, U.S.C 1983 et seq.; see also Title 18, Sec 241-42).
ANNUAL FEES
$35.00 (Member) - $50.00 (Family) - Free (Children)
I enclose the fees required as consideration for my/our membership affiliation and agreement. I agree to pay these fees yearly, unless otherwise instructed. The term of my/our membership begins with the date of the signing of this agreement. I hereby certify, attest and warrant that I have carefully read the above and foregoing THB membership agreement and I (and my family) fully understand and agree with its terms and conditions.
Member’s Signature - By Signing This Electronic Form, You Agree With All Statements Above & Below
(Required)
Member’s Signature
Spouse’s Signature - By Signing This Electronic Form, You Agree With All Statements Above & Below
Spouse’s Signature
CHILDREN
(name, age, gender)
Child -#1
Child -#2
Child -#3
Child -#4
*First Nation Medical Board (“FNMB”) d/b/a Turtle Healing Band is authorized by agreement with Crow Nation to create a Tribal Health Care Program that licenses Tribal Providers of indigenous medicine to provide indigenous healthcare services for its private THB members. Tribal Providers include allopaths (MDs), osteopaths (DOs), chiropractors (DCs), naturopaths (NDs), homeopaths (HMDs), and other healing arts (i.e., nurses, massage therapists, colon therapists, etc.). Private membership includes indigenous medicine patients, members of the Crow Nation, and Crow Nation affiliates.
Statements
By checking this box I am agreeing to:
(Required)
abide by all the terms and conditions listed herein
All information I have provided by me herein is true and complete to the best of my knowledge:
(Required)
I agree to all the statements above
Phone
This field is for validation purposes and should be left unchanged.
62454