USMRA Individual Candidate for Decoy Certification Application

USMRA Decoy Certification Candidate Application

Candidate Full Name *

First Name Last Name

USMRA Membership Number *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

USMRA Club Affiliation *

Phone Number

Area Code Phone Number

E-mail *

Contact Preference *

Phone Email Facebook

Previous Decoy Certifications

Last Certification Date

Date

Last Tetanus Shot Date *

Doctor's Name *

First Name Last Name

Doctor's Contact Info Phone or Email. You will need to attach an approval from your doctor stating you are able to participate in "Contact Sports" *

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

DECOY CERTIFICATION EVENT INFORMATION

Certification Event Date *

Date

Club hosting certification *

Dog(s) you are requesting to use. Dog Name, Titles. Handler's Name. Handler's Contact Info *

By submitting this application, I agree to abide by the USMRA Code of Conduct, rules and regulations of the USMRA (United States Mondioring Association) and its stated purposes of promoting Mondioring, sportsmanlike conduct and fair and humane training at all dog sport activities. I agree to keep myself informed on current by-laws, USMRA Code of Conduct and policies and procedures of USMRA via the www.usmondioring.org website or by requesting a copy from the USMRA Secretary. I am aware of the inherent risks of decoy activities, and hold the USMRA harmless for any medical expenses or other losses I incur as the result of my participation in the certification or future activities as a USMRA decoy. I also agree that I will send a copy of my doctor's note to the USMRA Secretary as well as my current decoy book pages at the end of each year. *

Agree

Signature

Date *

Date

ATTACH Doctor's Note of Medical Clearance for Candidate to participate in "Contact Sports" *

Copy of Decoy Book Pages