Permit # _____ - 20___

BAGANÉWNIKAN • TRIBAL POLICE

2017 POW WOW CAMPING PERMIT APPLICATION

All persons that camp on the Pine Creek Reservation (rustic area only) are required to register. Please fill out this form completely, and return it to the Tribal Police. Please Print or Type LegiblyApplicant Name:                   Date of Birth:      

Last First Middle (mm/dd/yyy)Address:      

City:      

State:      

Zip:      

Telephone Number:      

Driver’s License Number/State:      

Vehicle Make:      

Model:      

Color:      

License #:      

Emergency Contact Person:      

Telephone #:      

Number in Party:      

Type of Camp (tent, trailer, pop-up):

      Start Date:       End

Date:      

NAME OF OTHER PERSONS IN CAMPSITE DATE OF BIRTH

                       Last First Middle (mm/dd/yyyy)

                       Last First Middle (mm/dd/yyyy)

                       Last First Middle (mm/dd/yyyy)

As the PERMIT HOLDER, I understand that I am responsible for maintaining the campsite in a clean and orderly fashion. In addition, I acknowledge that it is my responsibility for maintaining a peaceful campsite and not allowing violations of the law, including the use of ALCOHOL AND DRUGS. The use or possession of firearms is prohibited. Persons that are found to be violating the law MAY BE asked to leave the Pine Creek Reservation.

Persons camping on the Pine Creek Reservation are doing so at their own risk and peril. The applicant further agrees to hold harmless the Nottawaseppi Huron Band of the Potawatomi and it’s agents for all incidents that occur while camping on the Pine Creek Reservation.

The Tribal Sex Offender Registration and Notification Code requires that any Sex Offender who lives, works, or goes to school on Tribal lands, or stays on Tribal lands for more than seven (7) days must register with the Tribal Police. Failure to register as required will result in federal and/or Tribal sanctions. Additionally, Sex Offenders are prohibited from being any place utilized for overnight camping or gathering for families and minors, including the NHBP Pow Wow grounds. (Sec. 4.24B.3)

Applicant’s Signature:

Date

PINE CREEK INDIAN RESERVATION2221 1 ½ MILE ROAD • FULTON, MI 49052

:

PINE CREEK INDIAN RESERVATION1485 MNO-BMADZEWEN WAY • FULTON, MI 49052