American Cancer Society, Ohio Division, Inc.

Bark For Life

Registration and Waiver Form Saturday September, 21st 2013 South Shore Veterans Park, Oregon, Ohio
PLEASE PRINT ALL INFORMATION

If you are associated with a Relay For Life team please list team name_________________________________________ Canine Owners Name:______________________________________________________________________________ Canine Name/Names:_______________________________________________________________________________ Address:_________________________________________City:_________________________State:____Zip:__________ Home Phone: ( )_________________________ Work Phone: ( )__________________________Ext.________ Fax ( )________________________________ Cell Phone: ( )_____________________________________ I prefer to be contacted at: Home Work Cell (please circle one) Emergency Contact Name:______________________________Emergency Contact Phone: ( )_____________________ I am 18 years old or under: ~ No ~ Yes (If so, please list age:_______) Emergency Email:__________________________ Enclosed is my check payable to American Cancer Society for my registration of $10 for the Bark For Life ($5 for each additional dog) Please check Bandana Size LARGE DOG __ SMALL DOG__

Please charge my credit card for my $10 registration fee ($5 for each additional dog) for the Bark For Life event. Please fill out all information clearly and completely. Your signature is required to process the credit
card.

Charge my: (circle one)

Visa

MasterCard

American Express

Name on card:_____________________________________________Telephone #_________________________ Address:___________________________________________________________________________________ City:____________________________________________________State:____________ Zip:_______________ Account number:________________________________________________Exp Date:_____________________ Signature___________________________________________________________________________________

Mail registration form and check to Randi Brower- 308 Ember Oregon, Ohio 43616 ALL DOGS MUST BE ON A 6FT. LEASH FOR SAFETY AND CONTROL
W A I V E R : Each canine owner MUST read and sign. As a participant in the Canine 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 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.

Please be sure to turn this form over and read and sign !!!!! We require your signature to participate!

BFL FY13 Registration Waiver

Please read and acknowledge the waiver below. Thank you for your cooperation! As a participant in Bark For Life, I, for myself, my executor, administrators, heirs, devises and assigns do hereby discharge the American Cancer Society, Ohio Division, Inc., the event site, their management, their officers, board members, employees, members, sponsors, volunteers, 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 matter arising from or growing out of my participation or that of my child and/or dog in the event. The American Cancer Society, Ohio Division, Inc. provides Bark For Life participant ("Bark Participant") Web pages as a service (not available in all areas). All donations received through the Bark Participant pages are contributions for which no goods and services have been provided. Therefore, Bark Participant pages shall not contain any language which suggests that merchandise will be provided in exchange for their contribution. Bark participants are expressly prohibited from offering merchandise sales, prizes, raffles, giveaways, lotteries, contests, tournaments, lucky draws, or any games of chance on their Bark Participant pages either as an outright token action or as an inducement to solicit donations. As a Bark For Participant, you are limited to disseminating information that is for the benefit of the American Cancer Society, Ohio Division, Inc., Bark For Life. The Bark For Participant pages are expected to represent the American Cancer Society, Ohio Division, Inc. in a professional manner in accordance with the Internet Privacy Policy. Furthermore, Bark participants are expressly prohibited from including information on their Bark For Life Web pages that are inconsistent with the American Cancer Society's mission and values. Bark For Life Web pages shall not advertise for-profit business. Examples of prohibited subjects include, but not are limited to, the sale or promotion of any goods or services, an endorsement or perceived endorsement of any goods or services, support or opposition of a political party or a political candidate, materials affiliated with tobacco or tobacco-related products and any other products inconsistent with the Society mission, content of any nature which may result in fraud or misrepresentation to the public, pornographic or otherwise offensive sexual materials, racially or ethnically prejudicial materials, overtly religious materials or any other information that may be offensive to the general public. Bark Participant agrees to indemnify the American Cancer Society, Ohio Division, Inc. for all fines, fees and expenses incurred as a result of the breach of any contractual obligations of the Bark Participant. I give my full permission for the use of my name and photograph in this event. I also give my full permission for such first aid as deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment. ***If I am under the age of 18, my parents have consented to my participation at the American Cancer Society Bark For Life. When I am on the premises of the American Cancer Society, Ohio Division, Inc. or at an American Cancer Society, Ohio Division, Inc. sponsored event, my parents have given their consent for me to participate in Bark For Life and have agreed to all of the Bark Participant Donation and Solicitation Agreement Terms and Conditions on my behalf. I also agree to complete and return to my ACS, Ohio staff partner the Youth Participant Waiver Form signed by myself and my parents.*** Content Disclaimer The American Cancer Society, Ohio Division, Inc. does not exercise any editorial control over the information you may find on any Bark Participant Web pages (if applicable). Opinions expressed on Bark Participant Web pages do not necessarily represent the official views of the American Cancer Society, Ohio Division, Inc. Participant Signature:____________________________________________
(Signature of parent or legal guardian if human participant is under 18 )

Date:

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For ACS office use only Date Entered into TES: ____/____/____ Entered by:_______________________