2021 Midwest JRT Club Membership Application

Primary Member *

First Name Last Name
Second Adult

First Name Last Name
Family Members
Email Address *

Confirmation Email example@example.com
* The email addresses for the primary member and second adult cannot be the same. Please provide a different email address for the second adult.
Second Email Address

Confirmation Email must be a unique and valid address
Primary Telephone *

Area Code Phone Number
Second Phone

Area Code Phone Number
Address *

Street Address

City State/Province

Zip/Postal Code Country

Persons applying for or renewing a current membership in the Midwest Jack Russell Terrier Club and members of their immediate family shall not be a member of any conflicting Jack Russell Terrier organization as defined by the Jack Russell Terrier Club of America. Applicants shall not register their Jack Russell Terriers with any conflicting organization or any all-breed kennel club. Membership may be terminated, suspended or refused by the Midwest Jack Russell Terrier Club Officers for any conduct which may be considered likely to prejudice or damage the image of or interfere with the efficient running of the Club or compromise the breed standard in any way.
I hereby apply for membership in the Midwest Jack Russell Terrier Club *

I certify that I neither belong to any conflicting Jack Russell Terrier Organization nor do I register my Jack Russell Terriers with any all-breed kennel club.
Signature *
Date

Month Day Year
date
The Midwest JRT Club publishes an online member directory April through September. The directory contains members personal names, emails, postal address and phone numbers, information that could become publicly available. Members may choose to restrict some information. The names of minors are never included in the member directory.
Do Not Publish

Address Primary Telephone 2nd eMail 2nd Telephone

I want to help

Contact me...
Jack Russell Rescue: I can

foster a rescue. adopt a rescue. Rescue transport.
LIABILITY RELEASE: In consideration of my participation as a member of the Midwest Jack Russell Terrier Club (the "Club") at meetings, seminars, play days, fun days, trials and any other such events, I hereby waive any and all claims for, and remise and release the Club, its members, officers, directors, and/or any participants from any and all liability for damages to person or property, accidents, or injuries caused by or in any way arising out of or related to participation in any Club activities, including the period of time immediately prior thereto and immediately thereafter the conclusion of the activity. Each signer understands that by participation he or she is a joint venture participant and assumes all risks of liability to themselves occasioned by this participation. The release and waiver shall be effective from the date of signing.

EMAIL OPT-IN: I understand that the primary method for club communications is email, both bulk and individual. I opt-in to all email lists that the Midwest JRT Club maintains and may, at any future date, opt-out from any or all bulk email communications.
Liability Release *

Release
Bulk eMail opt-in *

all email addresses only primary address
Initial
Release/Opt-In

Month Day Year
date