American Cancer Society Bark For Life of ParadiseMoore Road Ball FieldSeptember 17, 2011

Registration begins at 9am

Registration and Waiver Form PLEASE PRINT ALL INFORMATION

Canine Owner’s Name: Canine Name/Names: Address: City: State: Zip:

This is my address at: Home Work (please check one)

Home Phone: Work Phone: Cell Phone: Email:

I prefer to be contacted at: Home Work Cell Email (please check one)

If you are under 18 years of age: Emergency Contact Name: Emergency Contact Phone:

Yes No The canine’s owner is a cancer survivor.

Return form & payment to: Dog Contests and Games*

Nevin & Witt Insurance Best Dressed6848H Skyway Pet TricksParadise, CA 95969 Vote for the “BFL” 2012 Mascot

Waiver – Each canine owner must read and sign As a participant in the American Cancer Society Bark 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 give my full permission for the use of my name and photographs in this event. I 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. I agree to obey all rules of the American Cancer Society Bark For Life. I will keep my dog(s) on a leash (maximum 6’) at all times.

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

Please visit www.relayforlife.org/paradiseca for information on Paradise Relay For Life event.

*See reverse side for information on contests and games

Registration fee _______ $20 (one dog) ________ $30 (2 dogs)

Please enclose a check payable to the American Cancer Society.

Canine Bandana Size: Small Medium Large(Please enter quantity of each if registering more than one dog on this form)

DOG CONTESTS AND GAMES INFORMATION

Best Dressed. Bring your canine friend in their best outfit. During the event we will have a “fashion show’.

Pet Tricks. What can your dog do? Each entry will be given time to “show their stuff”.

Vote for “BFL” 2012 Mascot – Send us a picture of your dog if you would like to enter them in the Bark For Life 2012 Mascot Category. All pictures will be posted at the site for everyone to vote. The winner’s picture will be on all posters and in the program for the Bark For Life 2012. Winner will lead the walk in 2012. Please put your dog’s name and breed on the picture that you submit. PLEASE NOTE: no pictures will be accepted for the “BFL” 2012 Mascot the day of the event – all pictures must be submitted NO LATER THAN September 1, 2011.

Ballots will be given to each registered participant to vote for their favorite best dressed canine, best pet trick, and their vote for the “BFL” 2012 Mascot. Winners of the best dressed canine and best pet trick will receive a prize.