PSD Clinic Registration Form

Ben Means Clinic Registration Form

November 14, 15, 16, 2002 - Bluejacket, Oklahoma

Deadline November 6th

Make sure form is completed, legible and signed.

Enclose check or money order (US Funds Only)

in the amount of $150.00 per dog per day.

Please make payable and return by mail to:

Ben Means, 442154 E 140 Rd, Bluejacket, OK 74333.

If you have any questions, please call us at 918-784-2643.

Breed of Dog ______________ Name of Dog_________________________________________

Date of Birth ______________ Sex (circle one) M or F

Has your dog been on stock? If Yes, please describe. _____________________________________

______________________________________________________________________________

Name_________________________________________________________________________

Address_______________________________________________________________________

City/State/Zip___________________________________________________________________

Owner Ph No ( ) ______________________ Owner E-mail _____________________________

My goals for this clinic are:

__________________________________________________________________________________

Spectators please record your name and address and sign this form.

AGREEMENT TO HOLD HARMLESS, WAIVER AND ASSUMPTION OF RISK:

In consideration for participation in an event given by Ben Means, Leslie Collins Means, the Perfect Stock Dog Training Program, I agree to assume all responsibility for any claim, loss, or damage, of whatever kind or nature, whether to person or property, which may be caused at or near this event, either directly or indirectly, by me or the dog(s) I have entered in or brought to this event. I further agree that I will hold the event sponsors and participants harmless and defend them from any and all liability for any injury, claim, damage, or loss, of whatever kind or nature, whether to person or property, caused at or near this event, whether directly or indirectly, by or to myself, family members, guests who may attend, or any dog I have entered in or brought to this event. I agree to indemnify the event sponsors and participants for any loss, cost, or expense including attorneys fees and costs, to which the event sponsors or participants might be subject as a result of any claim, suit, loss, or damage caused in any way as a result of any claim, suit, loss, or damage caused in any way by any act or negligence on my part or on the part of any dog(s) I have entered in or brought to this event. I acknowledge that while Ben Means, Leslie Collins Means, the Perfect Stock Dog Training Program may provide sanctioning for this event, it does not have and does not exercise control over the conduct of the event or those present. I certify and represent that the dog(s) I have entered in or brought to this event is/are not a hazard to other dogs, other animals, or to people.

I also agree to be responsible for paying the market value for any animal mortally injured by my dog(s) and for any vet bills incurred on any animals by my dog(s). I understand that attendance at this event is not without risk to myself or my dog(s) because some of the dogs and livestock to which I will be exposed may be difficult to control and may be the cause of injury even when handled with the greatest amount of care. I also understand there is no videotaping allowed and agree to not videotape.

I certify that I am the actual owner or owner's authorized agent of the above entered dog.

SIGNATURE: DATE: