CALL NAME

BREED          

SEX

HT AT WITHERS

Standard Class (enter number of runs)

Jump Ht (Circle One)

8”  12”  16”   20”  24””  26”

[     ] Novice/ Rally A

[     ] Open /Rally B

[     ] Excellent/ Utility

OWNERS

OWNERS ADDRESS

CITY, STATE &  ZIP +  4

HANDLER

FEE ENCLOSED

           $ 

AGREEMENT

I/we certify and represent that the dog entered is not a hazard to persons or other dogs.  I (we) agree that the club holding this event has the right to refuse this entry for cause, which the club shall deem sufficient.  In consideration of the acceptance of this entry, I (we) agree to hold the event-giving club, their members, director of services that are necessary to hold this event and any employees or volunteers of the aforementioned parties, harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or about the event premises or grounds or near any entrance thereto, and I (we) personally assume all responsibility and liability for any such claim; and I (we) further agree to hold the aforementioned parties harmless from any claim for loss, injury or damage to this dog.

Additionally, I (we) hereby assume the sole responsibility for and agree to indemnify, defend and save the aforementioned parties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting from, sustained by any person or persons, including myself (ourselves), or on account of damage to property, arising out of or in consequence of my (our) participation in this event, however such, injuries, death or property damage may be caused, and whether or not the same may have been caused or may be alleged to have been caused by the negligence of the aforementioned parties or any of their employees, agents, or any other persons.

SIGNATURE of owner or his agent duly authorized to make this entry. ( Parent or Guardian Signature

if Owner is Under 18)_______________________________________________________________

TELEPHONE NUMBER (Include Area Code) ___________________________

E-Mail (Please print clearly)_________________________________