RSA October Trial 2019

RSA Fall Trial
Handler Information

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Country *

Phone *

Email *

UScA Membership

UScA Membership Expiration

UScA Home Club

Date and location of BH

Owner Information

Same as handler? *

Yes No

Owner First Name

Owner Last Name

Owner Street Adress

Owner City

Owner State

Owner Country

Owner Postal Code

Owner Phone

Owner Email Address

Dog Information

Registered Name *

DOB *

Sex *

Male Female

Breed *

Breed Register *

Registration Number *

Tattoo/Microchip *

UScA or UScA Registered Scorebook *

Working Titles

Handler Owned and Trained (HOT)

Yes No

Rule and Liability Waiver

I will be fully and solely responsible for the actions of myself, my family and my dog(s) while engaged in any club activities, whether on club property, tracking fields, training grounds, competitions, shows or any other location;
I will maintain control of and be responsible for the welfare of my dog(s) during all club-related activities;<\li>
I hereby waive, release, hold harmless and defend this club, its officers, directors, members, guests, club and third-party trainers/educators, judges, agents, property owners and their successors from any and all claims of loss, injury or disease to myself, my family members, my property or my dog(s) arising directly or indirectly from, or in any way related to, participation in or attendance at any activities of this club whether on or off club property;
To the fullest extent permitted by law, I shall indemnify, hold harmless and defend this club, its officers, directors, members, guests, spectators, club and third-party trainers/educators, judges, agents, property owners and their successors and assigns from any and all claims of loss, injury or disease to any other persons, dogs or property arising directly or indirectly from, or in any way related to, the participation of myself, my family or my dog(s) in, or attendance at, any activities of this club whether on or off club property;
In case of emergency, the club may in its sole discretion authorize medical treatment for my family, my dog(s); or myself
The club has my permission to take and use photographs, videotapes and other recordings of club activities involving myself, my family or my dog(s) for any lawful purpose without compensation; and
I will abide by club and event rules.

The club hereby disclaims any undertaking to protect personal property, including vehicles and contents, equipment, cameras and valuables, from loss, theft, damage or vandalism and disavows any responsibility for any and all such losses that may occur at any club activity.

By signing this form, I certify that my dog(s) are physically and mentally fit for training, competition, and contact with the public, dogs and other participants, have current rabies and other vaccinations and are free from all communicable diseases.

Signature *

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