American Cancer Society(1)

							American Cancer Society
Bark For Life of Fairless Hills
Saturday, May 15, 2010                       10am-1pm (Rain or Shine)
Falls Township Park, Pavilion B
(dog walk that contributes to Relay For Life of Fairless Hills)


Participant Registration & Waiver Form
(Required for all canines, one form per participant; multiple dogs may be registered together as a family unit).

                                                    PLEASE PRINT ALL INFORMATION
Canine Owner's Name: _____________________________________________________________________
Canine Name(s): __________________________________________________________________________
Address: _______________________________________ City: _______________ State: _____ Zip: _______
This is my address at: Home  Work (please check one)
Home Phone: (         ) _____________________ Work Phone: (     ) _____________________ Ext. ______
Cell Phone: (       ) _____________________ Email Address: ______________________________________
I prefer to be contacted at:  Home  Work       Cell      Email (please check one)
I am 18 years old or under: Yes No Age: _____
Emergency Contact Name: _______________________ Emergency Contact Phone: (        ) _______________
Employer: ____________________________________
Will your employer match your donations: Yes No             Is your employer a sponsor of this relay: Yes No
If no, do you feel your employer would be interested in hearing more about sponsorship opportunities: Yes No

REGISTRATION FEE: $15 If registered by May 14, 2010 OR $25 Day of event
 Enclosed is my registration fee (checks payable to American Cancer Society) $_____ x _____ dogs = $______.
We encourage all dogs to raise $100 min for the event. All dogs who raise $100 or more will be honored at both the Bark & Relay.

Canine Bandana's # needed: _____ (please indicate quantity if registering more than one dog on this form).

Please return this form and your registration fee to Cindy Calderone: 48 North Court Lane, Levittown PA 19054
Questions: Please call Cindy Calderone 267-987-3441 or Monica Johnson 215-712-3291
WAIVER: Each canine owner MUST read and sign.
   As a participant in the 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(s) in this event.
   I give my full permission for the use of my name and photographs and that of my dog(s) 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(s) on the
     premises or prior to transport to a medical facility for further treatment.

Participant Signature: _____________________________________________ Date: ____________________
                       (Signature of parent or legal guardian if human participant in under 18)

ADDITIONAL INFORMATION: Canine Owner is a cancer survivor (please circle one): Yes                                     No
Date of Diagnosis: _________________ Cancer Type: _________________________

Canine Owner is a caregiver to a cancer survivor (please circle one): Yes No
 Visit www.relayforlife.org/pafairlesshills for information on the Fairless Hills Relay For Life and Bark For Life.


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