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American Cancer Society: Bark For Life May 23, 2010 Relay Site Name: Avon Lake Participant Registration and Waiver Form

(One form per participant; multiple dogs may be registered together as a family unit)

PLEASE PRINT ALL INFORMATION

Canine Bandana Size:

SMALL

LARGE

_____

_____

(Please indicate quantity of each if registering more than one dog on this form)

REGISTRATION FEE: enclosed is the Registration fee of $10 per participant/dog in advance. Mail this form with the fee/fees to Shannon Goulding, C/O D.O.G. Apparel, 33757 Lake Road, Avon Lake, Ohio 44012. Questions? Call Shannon or Molly at 440.933.5297 ext 304. **On-site registration is $20 per participant/dog**

WAIVER: Each dog owner MUST read and sign.

  • As a participant in Relay For Life, I, for myself, my executor, administrators, and assigns, do hereby release and discharge the American Cancer Society, 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 dog/dogs in this event.

  • I understand that I may be photographed, filmed or videotaped at the event. I hereby irrevocably grant to ACS, its affiliates, licensees and collaborators the absolute right and permission to use my likeness and/or voice for any purpose whatsoever, including commercial advertising. I hereby release, discharge and agree to save harmless ACS and its employees or agents, affiliates, legal representatives or assigns and all persons acting under its permission or upon its authority or for whom it is acting, from any liability by virtue of any publication of my likeness, including, without limitation, claims for libel or invasion of privacy.

  • I also give my full permission for such first aid as is deemed necessary to be provided to me or my dog/dogs on the premises or prior to transport to a medical facility for further treatment.

Participant Signature:

________________________________________________________ Date: (Signature of parent or legal guardian if human participant is under 18)

_____/______/____

BARK FOR LIFE - PAWS WITH A CAUSE MAY 23, 2010 Sign In & Registration start at 8am at Paws by the Lake 33757 Lake Road, Avon Lake, Ohio 44012 Walk begins promptly at 9am

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