SECTION 1 : Your
Information
E-mail Address
First Name:
Last Name:
Address (Line
1):
Address (Line
2):
City:
County
State
Zip Code:
Area
of state (ex: N, S, W, E, SW,NW
Main Phone:
Work Phone
cc information
16 digits
exp date ex: ( 0311)
PAY BY PAYPAL
Who will be
primarily responsible for the coaching of
your dachshund?(please list two
persons )
SECTION 2 : NAME OF
DOG BEING ENTERED PLEASE SUBMIT A SEPARATE REGISTRATION FOR
EACH PET
Names of Dog(s)
Please indicate
THE FOLLOWING INFORMATION so your pet can be placed with compatible pets
during competition by checking all applicable boxes.
Breed
Gender
Age
Size
Dachshund
Male
Under
1 year *
Mini
(12 lbs. and under)
Dachshund
Mix
Female
1-3years
Tweenie
(13 - 24 lbs.)
4-7
years
Standard
(25 lbs. & over)
8
years and up
SECTION 3 : Your
Veterinarian
We require information that you
have a veterinarian. If
you do not submit this information now, you must
have it before the time of your registration..
Vetīs Name
Address (Line 1):
City:StateZip Code:
Contact Phone:
I agree that I am at least 18 yrs of age
and am submitting my dog for Registration in the event
of The Dachshund Derby. I also agree that all the
information above is true and accurate.
If filing electronically, your typed name
followed by your email address (eg: John Doe,
john_doe@aol.com) entered below will constitute
your "electronic submission signature
Signature:
Date:
Click
the submit button to enter your REGISTRATION
By
entering, I agree to adhere to all the rules and decisions
of the Management of the Kentucky Dachshund Rescue
concerning the running of the race and all results, all
decisions of the management are final and binding to all
participants.
1.
In consideration of participation in the Kentucky Dachshund
Derby I hereby and irrevocably agree to the following:
1.
Kentucky Dachshund Rescue, its affiliates, agents and all
other related sponsors may use for advertising and/or other
promotional purposes, my name and/or image, and/or voice,
and/or biological information on radio broadcasts or
otherwise in any honarable or legitimate way, in any other
medium in connection with the contest.
2.
With my particpation in this contest, I remise , release,
and forever discharge and agree to indemnify and hold
harmless Kentucky Dachshund Rescue, its affiliates,
successors, employees, sponsors, agents, and all others
connected with them and the contest from any liablity,
claims, actions, and damages arising in any manner from said
contest or receipt and use of the contest prize(s).
3.
I further, hereby affrim that: a. I am not
employed by Kentucky Dachshund Rescue b. I am not an
immediate family member of anyone employed by Kentucky
Dachshund Rescue, c.