2014 Bark for Life Registration Form Pre

2014 Bark for Life
Registration Form
Pre-Registration (prior to 9/3/14) $10
Registration (9/3/14 – 9/14/14) $15
Date: Sunday, September 14, 2014
Time: 11 am – 3 pm
Location: Brooklyn Fairgrounds (Rte 169 Brooklyn, CT)
The first 100 dogs registered will receive a Bark for Life bandana!!
To Register: Mail this form or drop it off at any *Citizens National Bank location (see below) or register the
day of the walk from 10-11am.
Please Print
One form per person & dog
Bark for Life Rules:
Team Name:_______________________________
1. Proof of rabies vaccination (or town license)
upon check in.
Your Name:______________________________
2. We reserve the right to turn away any dog that we
deem a threat to other participants.
Address: _________________________________
3. Limit one dog per person.
4. Dogs must be on a leach at all times.
City, State, Zip: ___________________________
(Maximum leash length 6 feet)
5. Dogs in heat not permitted.
Phone: __________________________________
6. Event is limited to dogs & people.
7. Participants are responsible for cleaning up after
Email Address: ___________________________
their dogs.
8. Children under 12 must be accompanied by an
Dog’s Name:_____________________________
adult.
9. Registration = one person & one dog
Breed: ___________________________________
10. HAVE FUN!
My dog is up to date on all shots: __ Yes __ No
Have you had a pet with cancer? __ Yes __ No
Is this pet a cancer survivor? __Yes __No
Walking in Memory of? ____________________
How did you hear about BFL 2014? ___________
Walking in Support of? ____________________
Release & Consent
I understand that participating in the walk includes an element of risk for both me and my dog. I should not participate unless my dog
or I are both physically able. I also understand that vehicle traffic will be present at the event and I assume any and all responsibility
including but not limited to falls, illness, contact with other dogs, spectators, weather or surface conditions on the path. I also affirm
that the dog I am walking has a current rabies vaccination. I agree to abide by the Bark for Life (BFL) Rules for this event.
I understand and give permission for BFL, their agents and others working for the event the free use of my name, picture, audio and/or
video recordings and that of my minor family members and pet in any broadcast, telecast, print or promotional purpose. I waive any
right I have to inspect and approve the final reproductions and any copy that may be used in connection with this event.
By signing this document, I agree to all terms & conditions of the above waiver.
X_____________________________________________________________
Date: ________________
Signature (Parent/Guardian)
*182 Main St, Putnam, CT, 06260
*3 Central St, Danielson, CT, 06239
*835 Riverside Drive, N. Grosvenordale, CT 06255
*13 Canterbury Rd, Brooklyn, CT, 06234
*148 Rte 171, Woodstock, CT, 06281
Pledge Form
2014 Bark for Life
Sunday, September 14, 2014
Mail this form to:
The Citizens National Bank
PO Box 6002
Putnam, CT 06260
Attn: Bark for Life 2014
Make all checks payable to: Bark for Life
Donor Name
Address
Amount
Cash Check
Total $ ________
Sponsored By:
The Citizens National Bank
*182 Main St, Putnam, CT, 06260
*3 Central St, Danielson, CT, 06239
*835 Riverside Drive, N. Grosvenordale, CT 06255
*13 Canterbury Rd, Brooklyn, CT, 06234
*148 Rte 171, Woodstock, CT, 06281
Celebration Marker Order Form
In Tribute or In Memory
Help fight cancer and honor your pet companion with a Celebration Marker. Our pets provide unconditional
love, joy, security and compassion. A pet does not judge our human inabilities or appearances. Help send
messages of love & support in tribute to or in memory of a beloved pet.
Minimum donation of $5.
Fill out the information below and return this form along with your $5 to:
The Citizens National Bank
PO Box 6002
Putnam, CT 06260
Attn: Bark for Life 2014
Pet’s Name: ________________________________
Your Name:________________________________
Address: __________________________________
Telephone: ________________________________
(Check all that apply)
Dog __
Cat__
In Honor of ___
Number of Markers: _______
*182 Main St, Putnam, CT, 06260
*3 Central St, Danielson, CT, 06239
In Memory of ___
Total Enclosed:$__________
*835 Riverside Drive, N. Grosvenordale, CT 06255
*13 Canterbury Rd, Brooklyn, CT, 06234
*148 Rte 171, Woodstock, CT, 06281
Teams @ Bark for Life 2014!!
TEAM ACE!
Make the most out of Bark for Life 2014 by creating your very own BFL team.
Benefits for BFL Teams:
 You get your very own, FREE team campsite at BFL
o Gather 4 or more friends/family to register & participate as a TEAM.
 Come up with a catchy (perhaps Animal themed) team name
 Design fun & funky team shirts
 Coordinate something cool to sell during BFL to help boost your team total!
To learn more about creating a BFL team, contact any of our BFL Committee Members:
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Shanon Sabourin: [email protected]
Sue Srednicki: [email protected]
Riley Williams: [email protected]
Lori Ruehle: [email protected]
Lisa French: [email protected]
Shannon Stahecki: [email protected]
*182 Main St, Putnam, CT, 06260
*3 Central St, Danielson, CT, 06239
*835 Riverside Drive, N. Grosvenordale, CT 06255
*13 Canterbury Rd, Brooklyn, CT, 06234
*148 Rte 171, Woodstock, CT, 06281

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