2018 INSURANCE WAIVER for Room Reservation

PCOTC WAIVER OF LIABILITY

For Facility Rental
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
I certify that:*

I am a volunteer member of Port Chester Obedience Training ClubAny dog(s) I bring for practice into Port Chester Obedience Training Club have up-to-date rabies vaccinations
FOR AGILITY EQUIPMENT USAGE ONLY:

I certify that I will only use the agility equipment if I have earned an agility title or have obtained permission to rent from a current PCOTC agility instructor.
Please list either agility titles OR instructor's name
I agree to abide by the by-laws, and policies, including the room reservation policies of the Port Chester Obedience Training Club ("Club"), and do hereby release the Club and all persons connected therewith, in any capacity whatsoever, from any and all liability, cost and expense to me or my pet(s) resulting from or attributable to my use of Club facilities.
Date*

MonthDayYear
Signature*
Should be Empty:

PCOTC WAIVER OF LIABILITY