MCSPCA Dog Walk - Registration Form

2004 MCSPCA Dog Walk Registration

Please enclose a registration fee of $30 for each adult, $15 for ages 6-16. (Onsite registration is $5 more per person.) Sponsor cards will be sent to you upon receipt of your registration form and fee. Make checks payable to MCSPCA and mail along with this form to:

MCSPCA Dog Walk
P.O. Box 637
Washington Grove, MD 20880

Please Print:

Name ______________________________________________________

Address ____________________________________________________

City/State/Zip ________________________________________________

Phone (H)_______________________ (W) ________________________

__________ Yes, I would like to register for the MCSPCA Dog Walk (please fill out information below and sign the Waiver and Release below).

__________ Enter me (us) in the Gold Collar Club Registration at $50/person (includes express registration, a seated lunch under tent, optional dog sitting service during lunch, and a surprise treat). (Please fill out information below and sign the Waiver and Release below).

ALL REGISTRANTS COMPLETE SECTION BELOW

Number of human walkers, adult	_________________________
Number of human walkers, ages 6-16	_________________________
Number of dogs walking	_________________________
Enclosed is my check for a total of $	_________________________

T-Shirt (circle sizes) sm med lg xl xxl

__________ I’m unable to attend the Pet Walk, but I will sponsor Blu, this year’s mascot, to help raise money for the MCSPCA. Enclosed is my check for $__________

Montgomery County SPCA Dog Walk Waiver and Release

In consideration of the acceptance of my/our entry, I/we hereby assume any and all risks which might be associated with the Dog Walk and Pet Fair. I/we waive and release any and all rights and claims of any nature for damages which I/we may have against the Montgomery County SPCA, its officers, directors, volunteers, and all others connected with this event, their representatives, successors, and assigns for any and all injuries or damages of any kind whatsoever suffered by me/us or my /our pets as a result of participating in the Walk and any related activities.

I/we hereby irrevocably grant to the Montgomery County SPCA all rights in, and permission to use, sell, reproduce, publish, and republish, my/our name, photograph, and any other likeness and biography of me/us, and those of my/our pets, for all purposes including, without limitation, publicity, fund-raising, and related promotional advertising purposes. I/we further hereby release and discharge the Montgomery County as SPCA from any claims and demands arising out of the use of the above-referenced information and material.

This waiver and release is executed on behalf of myself/ourselves, as well as my/our administrators , heirs, and assigns.

_____________________________________________________________
Name(s) (Print)

_____________________________________________________________
Signature(s)/Date (Parent or Guardian if less than 18 years old)