Registration Fees:

Adult Walker: $30 each
Child Walker: 13 and under with registered adult $20 each

Please complete and return with payment to above address as soon as possible.

Name ________________________________________________________________

Address __________________________________City___________State____ Zip__________

Phone ______________________Fax_____________________ Email _____________________

T-Shirt Size (included with registration)

___ Small ___Medium ___Large ___X-Large ___ 2X-Large

In agreeing to participate in the Wag-a-Tail Walk-a-Thon, I acknowledge that my dog and myself are physically able to undertake the Walk and waive any claims that may arise from the Walk which the walker or his dog may assert against any parties connected with the Walk. If I am under 18, the signature of a parent or guardian will appear below.

____ I Agree (please initial)

Total Amount Enclosed __________