W4A participant waiver

Pope Memorial SPCA Walk for the Animals

Participant Waiver
Participant Name*
ONE name per form
Mailing address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Individual - are you ?

Over 18Under 18
Team (4+ people) - are you ?

Youth teamAdult team
Name of Team/Leader
Number of team members
WAIVER AND RELEASE AGREEMENT:

I, and on behalf of my heirs, successors, and assigns, assume any and all risks associated with Pope Memorial SPCA of Concord-Merrimack County Walk for the Animals, and waive and release any and all rights and claims against Pope Memorial SPCA of Concord-Merrimack County, Northeast Delta Dental, NH Forest Society, NHTI, it's agents and representatives and any other connected with this event for injuries and damages of any kind suffered by myself or my animal.

I release all my rights to any and all photos taken while at Pope Memorial SPCA of Concord-Merrimack County SPCA, Walk for the Animals. (Children under 12 must be accompanied by an adult.)
Signature*

Clear
Should be Empty:

Pope Memorial SPCA Walk for the Animals