TOGETHER FOR GAYLE

Kip's Walk of Remembrance

May 11, 2013, 10am, at Caldwell Co. Primary School On-Site Registration begins at 8:30am Registration Fee: $20/adult, $10/child
includes t-shirt, wag bag (dog treats) & doggie bandana
PARTICIPANT REGISTRATION Walker: __________________________________________________________________ # of Dogs: ______ Additional Walkers (family members): ___________________________________________________ ___________________________________________________________________________________ Address: _________________________________________________________________________________
street city, state, zip

E-Mail: ______________________________________________ Phone: (_____)_______________________ Payment: ___cash ___check (please make checks payable to: SAFE Haven KY, P.O. Box 401, Princeton, KY 42445) T-Shirt Size: youth - small ___
WAIVER & LIABILITY RELEASE I agree to assume the risks of personal injury or property damage that may result from participating in this event. I also agree to release SAFE Haven KY and Lilly's Fund from all claims and liabilities, and to hold harmless SAFE Haven KY and Lilly's Fund, corporate sponsors, cooperating organizations and all parties connected with this event as a result of my participation. I will permit emergency treatment for myself (and/or my children) in the event of injury or illness while participating. I also give permission for use of my name (and/or my children's names) and photos taken of me (and/or my children) in promotional materials, publications, and organization websites. I agree to obey all traffic rules, safety guidelines, and dog participation guidelines for this event and I understand that SAFE Haven KY and Lilly's Fund reserves the right to dismiss anyone that disregards the event rules & guidelines or creates a disturbance. I agree to the following guidelines : 1. All dogs must have current rabies vaccination in order to participate. NO EXCEPTIONS. 2. All dogs must be on a leash at all times. 3. Participants are required to clean up all animal debris immediately after the occurrence. Participant Signature: __________________________________________________ Date: ___/___/___ __________________________________________________ __________________________________________________ Parent Signature Required for participants under 18 years of age: __________________________________________________ Date: ___/___/___

med.___ large___

adult - small ___ med.___ large ___ XL___ XXL___