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Registration Form:   

Please print*, complete, sign and return mail this page to register for this years event.

 

Each rider will receive an event t-shirt, patch and a Guide Dog of America Pin.

Passengers will receive a t-shirt only.

 

Pre-registration : $15.00 Donation for rider/driver, $5.00 for passenger

Day of ride: $20.00 Donation for rider/driver, $5.00 for passenger

 

 

Mail registration form and payment to:

 

        IAM&AW District 751                         Please Make Checks Payable To: 

        Attention: Puppy Putt                       Guide Dogs of America

        Lori Dorsey

             8729 Airport Rd East

             Everett, WA 98204

*For best printing, select "Shrink To Fit" from your "File, Print Preview" setting.


ALL PROCEEDS GO TO “GUIDE DOGS OF AMERICA”

                     

Name (Rider/Driver): _______________________________________________ Date of Birth: ____/____/____

 

Address: __________________________________________________________ Telephone: (___)___________

 

City, State/Province, Zip Code: ________________________________________ Shirt Size: _______________

 

Motorcycle: Make______________________Model_______________________ Year________ LIC#__________

 

Email: (optional)______________________________________________________________________________

 

Web Site: (optional)___________________________________________________________________________

 

 

Name (Passenger): _________________________________________________ Date of Birth ____/____/____

 

Address: __________________________________________________________ Telephone: (___)___________

 

City, State/Province, Zip Code_________________________________________ Shirt Size: _______________

 

Email: (optional)_____________________________________________________________________________

 

Shirt Size: __________________________________________________________________________________

 

 

RELEASE OF LIABILITY: I understand that state law requires vehicles and drivers/riders to be appropriately licensed and endorsed and to have their own liability insurance to operate on state roads and highways and that it is my responsibility to provide that insurance. I, therefore, release and hold harmless IAM&AW, District 751 Guide Dogs of America event volunteers, sponsors/supporters, participating merchants and event site owners and personnel from any responsibility for any damage or injury I may incur or cause while participating in this event. I have read this form and agree to the above statement (Signature(s) required).  Minors under 18 must have parents sign for them.

 

                      _________________________________________     __________________________________________

       Rider/Driver Signature (Required)                               Co-Rider Passenger Signature (Required)

 

PLEASE NOTE: Pictures taken at our events are for use in only professional publications, promotional materials and on this web site. Pictures taken at this event will and may not be used for distribution or re-sale in any way, shape or form. Participants agree and understand this note.

 

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