REGISTRATION FORM
Participant
Name________________________________________Age_____________
Gender: M
F
Address
_______________________________________________________________________
City, State,
Zip____________________________________________________________________________
Phone
(_____)____________________________Email:
________________________________
WAIVER:
In consideration of your accepting this entry form
and allowing me to participate in the 2005 Dog Walk/Human Race, I
hereby for myself, my heirs, executors and administrators waive and
release all rights and claims for damages I or my dog may have
against the 2005 Dog Walk/Human Race, the sponsors of the event, its
agents, representatives, successors and assigns for any and all
claims, injuries, actions and causes of action suffered by myself or
my dog at said 2005 Dog Walk/Human Race or which may arise out of
traveling to, participating in and returning from this event. I
also accept full responsibility for all action and behavior of my
dog during said event and agree to indemnify the HSGC for any
liability it incurs arising from any action by myself or my dog
against a third party during the 2005 Dog Walk/Human Race.
Participant
Signature_______________________________________________________________________
Parent/Guardian
Signature________________________________________________________________________
Parent/Guardian Signature (If participant is under 18 years of age.)
|
Pre-Registration Fee: $18
(Entrance fee, T-Shirt)
(May 27, 2005)
$10 (Entrance fee)
Deadline
Please Circle T-Shirt Choice: XS S M L XL
XXL XXXL (Adult Sizes)
Registration
Fee: $20 (Entrance fee, T-Shirt)
$12 (Entrance fee)
Please
Circle T-Shirt Choice: XS S M L XL XXL XXXL
(Adult Sizes)
Entrance fee can be combination of
Pledges/Cash or totally Pledges. Please hand in this
sheet with the donations you have collected at
pre-registration at the Humane Society or at the Walk/Human
Race itself. Donor checks must be payable to: Humane Society
of Genesee County.
Enclosed: $______________ Circle
one of the following: DOG WALK
/ HUMAN RACE |
Registration begins at 12 Noon at the Walk/Human Race.
Human Race-Awards to top overall
male & female finishers in the following age groups:
Runs: 15 & under, 16-19, and 5 year increments to 70 and over.
NOT A CHIPPED RACE- DOGS NOT PERMITTED IN THE HUMAN RACE
(If additional space is needed, please attach a
separate piece of paper.)
For more information, please contact the Genesee County Humane
Society at (810) 744-0511. |
