Brookings, South Dakota

2015 NAPWDA Dakota Workshop Brookings, South Dakota June 19, 20 and 21 Application Form

First and Last Name: ______Street, City and Zip Code: ______E-Mail Address: ______Home Phone #: ______Cell Phone #: ______

Check here if taking the NASAR SAR TECH II test only _____ Continue to Release of Liability Form.

K9 Name: ______K9 Age: ______K9 Breed: ______

Comments: (Previous certifications, problems or concerns)

If you have more than three dogs that you wish to test or train please contact Sandy Vernlund at 605-695-8444. Please sign the Release of Liability form on the following page.

of 2 Release of Liability I, the undersigned, request to participate in the 2015 NAPWDA DakotaWorkshop (here after referred to as workshop) to be held in/around Brookings, South Dakota, June 19-21, 2015. 1. I certify that I am over the age of 18 and in suitable physical condition to withstand the training rigors that may be associated with this workshop. I acknowledge that it is possible I may come in contact with blood borne diseases including, but not limited to, hepatitis and HIV or diseases which may be transmitted through contact with other bodily fluids or tissue. I agree to handle all HRD sources within strict aseptic procedures. It is solely my responsibility to consult with my physician to: (a) learn about the risks I may be exposed to as a result of search and rescue activities and appropriate vaccinations, if any, to reduce the risk of infection, (b) I am solely responsible to maintain the appropriate fitness level for such activities and (c) I am solely responsible to take (or decline to take) the advice of my physician with respect to such matters. 2. I agree to personally assume ANY AND ALL RISKS INVOLVED IN OR ARISING FROM MY INVOLVEMENT IN ANY ACTIVITY CONNECTED with this workshop including, without limitation, but not limited to, the risks of death, bodily injury, property damages, falls, canine bites to myself or to others, fire or explosion, the unavailability of emergency medical care, or the negligence or deliberate act of another person. 3. It is my responsibility to carry personal property insurance, medical insurance and insurance coverage for personal vehicles used during (including, without limitation, but not limited to) demonstrations or practice sessions during this workshop. 4. I agree to indemnify, defend and hold Brookings County K9 Search and Rescue, NAPWDA and NAPWDA Master Trainers and all of its representative members, associate members, agents, successors, assigns, affiliates, officers, and directors COMPLETELY HARMLESS AND NOT LIABLE and release them from ALL liability whatsoever and AGREE NOT TO SUE them on account of or in connection with any and all claims, causes of actions, injuries, damages, judgements, costs or expenses, including attorney’s fees, arising out of my personal actions or those of my canine(s) during (including, without limitation, but not limited to) demonstrations, training, or practice sessions based on death, bodily injury, canine bites, property damage, including consequential damages to myself or any other person. 5. I agree to release Brooking County K9 Search and Rescue, NAPWDA and NAPWDA Master Trainers and all of its representative members, associate members, agents, successors, assigns, affiliates, officers, and directors from any claim whatsoever which arises or may arise in the future on account of any first aid treatment or other medical services that are conducted in connection with an emergency during my time at the workshop. 6. My canine(s) shall be free from infection, contagious or transmissible disease. I am solely responsible for the health and safety of my canine(s) during, without limitation, but not limited to, this workshop.

Property Damage Agreement I, the undersigned, understand and agree that I am responsible for any and all damages caused by my canine(s) and myself, including, but not limited to, property damage and/or injuries to other dogs or people during activities associated with the 2015 NAPWDA Dakota Workshop held in/around Brookings, South Dakota, June 19-21, 2015.

Print Name: ______

Signature of Applicant: ______Date: ______

Complete form and mail to: BCK9SAR 21289 459th Avenue Volga, SD 57017 Page 2 of 2