Romp Waiver and Release – April, 2009

Name(s) _____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Address _____________________________________________

Phone _____________________________________________

Email _____________________________________________

Dog name(s) _____________________________________________

_____________________________________________

I understand that I am solely responsible for the health of my dog(s) and that they are up-to-date on vaccinations. Any medical issues that arise from our participation, is my responsibility.

I understand that I am solely responsible for any harm caused to or by my dog(s) and family members while my dog(s) is/are on the demised premise, Community Church of Syosset.

I hereby release and agree to hold harmless Community Church of Syosset, it's owners, members, employees, agents and the International Doodle Owners Group, Inc. and their representatives, from any and all liability, claims, suits, or damage of any nature or kind, or for any liability, claims, suits, actions, loss, injury or damage which I, my family or my dog(s) may sustain or which may be caused in any way by my dog(s). I specifically, without limitation, agree to fully indemnify Community Church of Syosset and the International Doodle Owners Group, Inc. and their representatives, Pat Lovell and Ivy Bates, for any and all such liability, claims, suits, actions, losses, injury or damage.

I certify that I have made full disclosure and have read, understand and accept the terms, conditions and statements in this agreement. Furthermore, I acknowledge that this agreement shall be effect and binding upon all members of my family and or party.

Signature: ___________________________ Date: _____________________________