Tuesday, 23 February 2016 14:48

2017 Dog Olympics

Dog Olympics / Waiver and Release of Liability Form

PART 1: WAIVER AND RELEASE OF LIABILITY

As the parent/legal guardian of the child below, I understand the nature of the activities that my child will be participating in during the week selected below at the Riverside County Western Riverside Animal Shelter during Spring Break Dog Olympics. I also understand the nature of domestic animals and that their behavior is sometimes unpredictable which can give rise to risks such as personal injury. Knowing this, I, and anyone who might claim on my behalf, release the Department of Animals Services and the Animal Solutions Konnection (ASK), the County of Riverside, its Agencies, Districts, Special Districts, and Departments, their respective directors, officers, Board of Supervisors, employees, elected or appointed officials, agents or representatives, from any and all claims and liability of any kind arising out of personal injury and property damage resulting from my child’s participation in activities during Spring Break Dog Olympics.
Name (electronic signature):*
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For (Child’s name):*
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Emergency Medical Information:
Any known allergies:
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Any physical limitations or other needs:
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Health care provider’s name, phone number and address:*
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Insurance carrier and policy number:*
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Emergency contact name and phone number if parents cannot be reached: (please list two)*
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Parent/legal guardian information:
Address:*
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Home Phone:*
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Work Phone:
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Mobile Phone:
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Other individuals authorized to pick up my child:
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PART 2: REGISTRATION

I am interested in signing my child up for the week of:*

Please select a week.

Name of Participant:*
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Age:*
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Sex:*

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Parent or Legal Guardians Name:*
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Phone (example: 123-456-7890):*
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Email:*
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Address:*
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City:*
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State:*
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Zip:*
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How did you hear about Critter Kiddz Camp?*
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PHOTO RELEASE:

By signing this form, I grant the right to photograph or video record my child or reproduce and use said child’s artwork, written work, picture, silhouette, and other reproductions of physical likeness in connection with Riverside County Department of Animal Services’ and the ASK Foundation’s promotions.

HOW TO PAY:

The cost of Spring Break Dog Olympics $100.

***You must register and pay for each child separately.

Once registration is complete, you will be redirected to Paypal through the ASK Foundation for payment.

PAY BY CHECK

Payments by check (payable to the Animal Solutions Konnection Foundation) or cash can be mailed or dropped off in person to:

Western Riverside County/City Animal Shelter
ATTN: The ASK Foundation
6851 Van Buren Blvd.
Riverside, CA 92509

Donate

For your convenience, we accept payment by Visa and Master Card.  We do not accept American Express or Discover credit cards.  We do not accept credit card numbers over the phone or through the mail.

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