Participant Name

Team Name (if applicable)

Participant Address

City State Zip Code

Home Phone (including area code)

Cell Phone (including area code)

Email address

Dog's Name

Vet's Name

Vet's Phone Number

Registration fee before the event is $10 per dog. When you submit the form, you will be taken to a confirmation page, which will include a link to PayPal, where you can then charge your entry fee by credit card.

Registration fee on the day of the event is $15 per dog.

ADDITIONAL INFORMATION:

I am a cancer survivor: Yes No

If yes, what was the date of your diagnosis?

If yes, what was the type of cancer?

I am a caregiver for someone who has cancer: Yes No

My dog is a cancer survivor: Yes No

If yes, what was the date of his or her diagnosis?

If yes, what was the type of cancer?

My dog is a caregiver for someone who has cancer: Yes No

Please read the following waiver and if you agree, click the button below and submit it.

 I waive and release all rights and claim for damage against the organizers or anyone else associated with Bark For A Cure, for any injuries suffered by me or my dog as a result of taking part in the day's activities.
 I will be responsible for the conduct of my dog, keeping him/her leashed at all times and cleaning up after my pet. I will not bring a female dog in heat or a dog known to be aggressive toward people or other dogs.
 I certify that my dog is up to date on vaccinations and has a current dog license.
 As a participant with the Bark for a Cure, I, for myself, my executor, administrators, and assigns, do herby release and discharge Bark for a Cure, the event site, their management, their officers, members, sponsors, organizers, or their representatives, or their successors, and all cooperating businesses and organizations from all claims of damages, demands, actions, and causes whatsoever, in any manner arising or growing out of my participation or that of my child in this event.
 I give my full permission for the use of my name and photograph in this event.
 I also give my full permission for such first aid as is deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment.

I further state that I am in proper physical condition to participate in the walk.

I understand that by clicking the submit button, I am providing the electronic equivalent of my signature.

I confirm and agree

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