Puppy Putt Registration

Registration Form:

Please print*, complete, sign and return mail this page to register for this years event.

Each rider will receive an event t-shirt, patch and a Guide Dog of America Pin.

Passengers will receive a t-shirt only.

Pre-registration by July 6th: $15.00 Donation for rider/driver, $5.00 for passenger

After July 6th or Day of ride: $20.00 Donation for rider/driver, $5.00 for passenger

Mail registration form and payment to:

IAM&AW District 751 Please Make Checks Payable To:

Attention: Puppy Putt Guide Dogs of America

Lori Dorsey

8729 Airport Rd East

Everett, WA 98204

*For best printing, select "Shrink To Fit" from your "File, Print Preview" setting.

ALL PROCEEDS GO TO “GUIDE DOGS OF AMERICA”

Name (Rider/Driver): _______________________________________________ Date of Birth: ____/____/____

Address: __________________________________________________________ Telephone: (___)___________

City, State/Province, Zip Code: ________________________________________ Shirt Size: _______________

Motorcycle: Make______________________Model_______________________ Year________ LIC#__________

Email: (optional)______________________________________________________________________________

Web Site: (optional)___________________________________________________________________________

Name (Passenger): _________________________________________________ Date of Birth ____/____/____

Address: __________________________________________________________ Telephone: (___)___________

City, State/Province, Zip Code_________________________________________ Shirt Size: _______________

Email: (optional)_____________________________________________________________________________

Shirt Size: __________________________________________________________________________________

RELEASE OF LIABILITY: I understand that state law requires vehicles and drivers/riders to be appropriately licensed and endorsed and to have their own liability insurance to operate on state roads and highways and that it is my responsibility to provide that insurance. I, therefore, release and hold harmless IAM&AW, District 751 Guide Dogs of America event volunteers, sponsors/supporters, participating merchants and event site owners and personnel from any responsibility for any damage or injury I may incur or cause while participating in this event. I have read this form and agree to the above statement (Signature(s) required). Minors under 18 must have parents sign for them.

_________________________________________ __________________________________________

Rider/Driver Signature (Required) Co-Rider Passenger Signature (Required)

PLEASE NOTE: Pictures taken at our events are for use in only professional publications, promotional materials and on this web site. Pictures taken at this event will and may not be used for distribution or re-sale in any way, shape or form. Participants agree and understand this note.

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