USMRA Individual Candidate for Decoy Certification Application

USMRA Decoy Certification Candidate Application

Candidate Full Name*

First NameLast Name

USMRA Membership Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

USMRA Club Affiliation*

Phone Number

Area CodePhone Number

E-mail*

Contact Preference*

PhoneEmailFacebook

Previous Decoy Certifications

Last Certification Date

Date

Decoy Certification Applying For

Last Tetanus Shot Date*

Doctor's Name*

First NameLast 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 NameLast Name

Emergency Contact Phone Number*

Area CodePhone 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"*

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Copy of Decoy Book Pages

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