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Membership Application PO Box 622 Casper, Wyoming 82602 |
NAME________________________________________________________________ PHONE_________________________________
ADDRESS_____________________________________________________________ EMAIL__________________________________
___________________________________________________________________ Under 18 Years of Age? YES_______ NO________
DOG'S NAME_______________________________________ BREED_______________________________________________________
AGE OF DOG_________________ DOG'S HEIGHT(at withers)_______________________ DOG'S WEIGHT________________
RABIES CERTIFICATE(please include with this application) YES____________________ NO _____________________
Have you ever been denied priviledges or suspended by any national dog club? YES______________ NO _____________________
If YES, please explain________________________________________________________________________________________________
I have read and understand the by-laws of the Agility
Club of Central Wyoming and agree to abide by those laws and rules as so
stated. I
understand that Dog Agility competitions and training
do involve some risks and that I may not hold the ACCW responcible for
any injury that
may occur as a result of my willful participation inthe
sport either to me or my dog.
SIGNATURE OF APPLICANT_______________________________________________________________ DATE__________________
SIGNATURE OF PARENT OR
GUARDIAN (if a Junior)
______________________________________________________________
DATE__________________
Dues MUST be summitted with the application. Please circle one of the following:
Regular $15.00
Family $25.00
Associate (out of town) $10.00
Junior (under 18 yrs old) $5.00
| ACCW USE ONLY:
Above Applicant is: ______Approved _______Not Approved DATE:_______________________________________ Signature of Board Member__________________________________________________________ |
