If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Registration Fees: Adult $25 | Family (2 adults plus children 16 and under) $60 First Name * Last Name * Address * City * State * Michigan Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone * List all names of participants besides yourself that are registering (first, last name) Team Information (For individuals as part of a team or family registering as a team) I am part of a team. I am not part of a team. Skip next two boxes. Team Name: Team Captain: Event Choice * 5K/3Mile Dash/Walk1 Mile Family/Fun Walk Number of Particpants Including Self (If for Family, use Family Registration below and skip this box and next) Subtotal Partipants-click to view If this is a FAMILY REGISTRATION, enter a number 1 in the box below. Do not use this if you have entered Number of Participants above. For Family only, Number of Family Members over 16. If none, leave blank. Subtotal Family-click to view Please choose a t-shirt size below for each participating member. Limit 2 per family please. There may be additional t-shirts available for purchase at $12 on the day of the event. Small (adult) Medium (adult) Large (adult) Total Waiver and Release In consideration of my being permitted to participate in the Humane Society of Livingston County's Doggie Dash on October 1st, 2016, the sufficiency of which I acknowledge, I, the undersigned, intending to be legally bound hereby for myself, my heirs, assigns, executors and administrators, do hereby waive and release any and all rights, claims, demands, or causes of action of any nature I may have against the Humane Society of Livingston County in Howell, Michigan College, and/or their directors, employees, agents, officials, volunteers, sponsors or any other representatives for any and all injuries or other damages of any kind that may be suffered by me or my dog in this event, from the date of this event forward. I hereby certify that my dog and I are physically fit and have sufficiently trained for the competition of this event. I acknowledge that any injuries sustained by me or my dog during the course of this event may be caused by or arise out of risks inherent to a race, of which I have full knowledge and which I assume. I further certify that all information and or documentation that I provided in connection with this application is true and accurate as of the date of the scheduled event. I will be responsible for the conduct of my pet, for cleaning up after my pet and for keeping my pet leashed at all times. I agree to indemnify and hold all sponsors of this event harmless against any and all claims, demands, or causes of action of any kind for any accident, injury or damage whatsoever caused to any person or property by me or my dog arising, directly or indirectly, prior to, during, or after the course of this event. I will additionally permit the free use of our names, pictures or likeness in broadcasts, newsletters or promotional materials. I understand that there may be dogs participating in this event. I understand the terms of this Waiver and Release and by my signature below affirm that I am signing this waiver and release freely and voluntarily. Acceptance of Waiver * I Agree with waiver For security reasons, please provide the answer to: 14+3 in the box below. * After clicking on the submit button, you will be redirected to the secure PayPal website where you will be asked to submit information to either pay by your PayPal account or with a credit card. Once the PayPal receives the payment, it will return you to this site.