Form

APPLICATION FOR DOG TROT

______________________________________ DOB:___________

Name

_____________________________________________________________

Address

______________________ Age: _________ Gender: Male _______

Phone No.

Female______

_____________________________________________

Email

I will be in the (check all that apply)

______ 5K ______ 1/2 Mile Medium Dog

______ 1/2 Mile Small Dog _______ 1/2 Mile Large Dog

T-Shirt Size: (NOTE FEE $20 PER PERSON IF WANT T-SHIRT; $15 W/O SHIRT)

____ Youth Small _____ Adult Small

____ Youth Medium _____ Adult Medium

____ Youth Large _____ Adult Large

_____ Adult XL

_____ Adult XXL

Liability Waiver:

In consideration of my participation in the 5K and/or .5 Mile Dog Trot, I do hereby agree to hold free from any and all liability, Greater Huntsville Humane Society, Therapy Partners, Inc., City of Huntsville, Alabama and/or their volunteers, organizers, officers, employees and sponsors. I do hereby waive all rights and claims for all injuries, illness, death, or damages incurred. I do declare that I am physically sound having medical approval to participate in the 5K/.5 Mile Dog Trot to be held Sat.,August 4, 2012 at John Hunt Park.

__________________________________ _________________

Signature (Parent if Minor) Date

Print and mail with payment (checks payable to The Dog Trot) to:

Max Carter Cost: $15 without t-shirt

3036 Dupree Drive $20 with t-shirt (or after July 18th)

Huntsville, AL 35801

PREREGISTRATION CLOSES WEDNESDAY, JULY 18. ;