ESWDA Membership Registration Form

Name*

First NameLast Name

Name - 2nd member

First NameLast Name

Age if Junior Member

Name- 3rd member

First NameLast Name

Age if Junior Member

Name- 4th member

First NameLast Name

Age if Junior Member

E-mail*

Phone Number:*

Area CodePhone Number

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is this a NEW Address?*

Are you a new member*

Have you been convicted of a crime?*

YesNo

Have you been convicted of a crime? Member #2

YesNoCheck if Junior Member

Have you been convicted of a crime? Member #3

YesNoCheck if Junior Member

Have you been convicted of a crime? Member #4

YesNoCheck if Junior Member

AKNOWLEDGEMENT

Recognizing the possibility of physical injury associated with canine training and in consideration for Eastern States Working Dog Association, Inc. accepting the registrant/member for its training programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the Eastern States Working Dog Association, Inc., its officers, members and its affiliated organizations and sponsors, their employees and trainers and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant/member as a result of the registrant's / member's participation in the Programs and/or being transported to or from the same, which transportation is required for participation in the Programs. During your participation in the Programs and/or related activities that is being hosted by the Eastern States Working Dog Association, Inc., you may be photographed and/or videotaped in connection with one or more Programs which are being documented by photography and/or videography during these activities. Your membership and/or registration and attendance at these events constitutes your express consent to use your likeness in connection with the production of video and / or photographic material and for any exhibition thereof in any / all media throughout the world for commercial, training and / or educational purposes. I certify that the answers given by me in this application are correct to the best of my knowledge. Further, I release the ESWDA Inc., its officers, agents, and members from any and all liability for any damages that may result from information collected during this membership application request. Verification of eligibility to join in the ESWDA, Inc. must be satisfied for an application for membership to be accepted. I also aknowledge that all membership fees are not refundable.

I acknowledge and accept that if I have sponsored a junior member, I will be responsible for said junior members actions and behavior at all ESWDA events and training. I agree to be at all events or training that said junior member is present at. If I am unable to attend said events or training, I will ensure an active ESWDA member or a legal guardian of said junior member will assume responsibility for said junior member at these events or training. I acknowledge and accept that if no active ESWDA member or legal guardian is able to be respnsible for said junior member, said junior member will not be allowed to participate or be present at any ESWDA event or training.

Certification

By placing my initials and date of submission in the boxes below I hereby certify that I am at least 18 years of age, all the information on this form is accurate and truthful and I expressly consent to the Eastern States Working Dog Association, Inc that may obtain any and all records of mine for the limited purpose of conducting a background and/ or criminal history investigation in order to satisfy the membership standards as set forth in the ESWDA by-laws. Further, I certify that I understand and agree to adhere to all ESWDA By-Laws and Rules, plus I have read, understand and agree to the above acknowledgement. I further certify I understand that any falsification of this application is grounds for disqualification of membership consideration, or dismissal from ESWDA, Inc.*

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2nd member

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3rd member

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4th member

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Date of Submission*

Purchase or Renew Membership*

Active Member$55.00

Multi Member Active $55.00

Quantity

Junior Member$ Free

Quantity

Total $0.00

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Thank you!

Eastern States Working Dog Association Inc.