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22nd Annual Strut Your Mutt
Registration Form
Walk for the animals of the Dubuque Regional Humane Society!
Saturday, May 16, 2015
Registration: 8 to 9 AM
Walk begins at 9 AM—rain or shine
3 WAYS TO REGISTER: (1) Register and collect pledges
online at www.dbqhumane.org, (2) Complete the printed registration and pledge forms and drop them off in advance, or mail it to
DRHS, 4242 Chavenelle Road, Dubuque, IA 52002, or (3) Bring
the forms with you to registration. We encourage those not collecting online donations to submit donations by 5 PM on May 15
to avoid waiting in line during check-in. Prizes will be dispersed
at event check-in.
PARTICIPANT INFORMATION:
Walker’s Name:_______________________________________
Dog’s Name (if applicable):______________________________
Address:____________________________________________
City/State/Zip:________________________________________
Phone:______________________________________________
T-Shirt Size (free if registration is received by 5/8):
Circle one: (Adult Small, Medium, Large, X-Large, XXL)
The goal of STRUT YOUR MUTT is to
bring the community together and raise
funds in support of the animals of the
Dubuque Regional Humane Society.
The more you raise, the more
you help the DRHS fulfill its
daily commitment to building lifelong bonds between people and
animals through adoptions, education, community outreach programs
and prevention of cruelty, and earn
fun prizes too!
THANK YOU! Your participation
makes a paws-itive impact in the
community and in the lives of lost,
abandoned, and unwanted animals.
Email:_______________________________________________
q Please sign me up to receive news and upcoming e-mails from the
DRHS! (The DRHS respects your privacy. We do not sell or share your
personal information!)
THANK YOU “TOP
DOG” SPONSORS:
REGISTRATION FEE:
q Pre-registration $25 (ends 5/15/15 at 7 PM)
q Day of: $35
CHILDREN 10 AND UNDER ARE FREE
If you are part of a team, please provide the team name. Each
team member must complete a registration form and pay the
registration fee. TEAM NAME:_________________________
PAYMENT METHOD:
q Cash
q Check #____________
q Credit Card
(Circle one: Visa Mastercard Discover)
Please make checks payable to the Dubuque Regional Humane Society.
q I cannot be a part of the dog walk, but I would like
to donate $____________.
Credit Card #___________________________
Exp. Date________
q Additional T-Shirt $10 each (Circle: S M L XL XXL)
Name on Card__________________________
TOTAL AMOUNT ENCLOSED: $_________________
Signature______________________________
EVENT DE-“TAILS”:
Date: Saturday, May 16, 2015
Registration: 8 to 9 AM Walk: Starts at 9 AM
Activities: 9 AM to Noon
Registration Fee: $25 (day of $35)
Kids 10 and under are FREE
T-Shirts: Register by May 8 and receive a
free t-shirt. Shirts will be available at the event
for $10 while supplies last.
l All participants must be 16 or older; those
younger than 16 must be accompanied by a
parent or guardian who has registered for the event.
l
Participants with dogs must provide verification of a current
Rabies vaccination. All dogs must be kept on a leash and licensed in their
appropriate jurisdiction.
l Participants with dogs are responsible for picking up their dog’s waste.
The DRHS will provide bags to participants and will have disposal sites on
the route.
l DRHS representatives reserve the right to refuse admittance to any
animals/participants that pose a potential danger to others.
l Prizes will be given out for the individual with the most pledges
and to the team with the most members. Record pledges and team
members on the attached forms.
WAIVER & RELEASE:
By registering for the Dubuque Humane
Society, hereinafter called Dubuque Regional Humane Society (DRHS)
Strut Your Mutt, you agree to the following Waiver and Release: I understand that participating in the DRHS Strut Your Mutt involves risks to me
and to my pet. I assume all risks associated with participating in this event.
I agree not to participate unless my pet and I are physically able, properly
conditioned and my pet has a current Rabies vaccination.
I have read and will abide by the rules of this event and any decision of
event officials.I agree to a global and general release. I hereby waive,
release and discharge the DRHS its directors, officers, employees and
agents, the City and County of Dubuque, their employees and agents,
volunteers and any sponsors, suppliers and all other individuals and
entities in any way assisting or connected with this event from any and all
loss of life, bodily injury property damage and/or loss, or personal loss of
whatever kind or nature whatsoever arising out of my participation in this
Set a Fundraising Goal!
q$100 q$200
q$300 q$400 q$500
Other: $__________
Collect Pledges - Earn Prizes
You Raise
You Earn
$50
Razor Stand (holds
cell phone/tablet)
$75*
3” Flashlight
$100*
$10 GC to Fuzzy Feet
Boutique
$200*
One-year membership to
Hadley’s Dog Park
*$75 and above receive prizes in
previous categories.
22nd
Dubuque Regional Humane Society’s
Annual Strut Your Mutt - Saturday, May 16, 2015
Pledge Form
Register: 8 to 9 AM
SPONSOR NAME
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
Set a goal! We recommend $50 for
individuals and $200 for teams. Ask
your friends, family and co-workers to
donate toward your goal.
l Collect in honor of, or in memory of,
a precious pet.
l Form a team to support shelter pets
with friends, family or coworkers.
l Those who register online can send
emails via their personalized fundraising
page and share information with their
social networks.
l Ask your employer to make a
matching donation for the funds you
have collected.
l
event, even though those claims and liabilities may arise as a result of action or inaction by individuals or entities released
by this Waiver Release.
I understand and agree that the DRHS does not insure against and accepts no responsibility for personal injury, property
loss or damage, which I may sustain. I hereby agree and covenant for myself, my heirs, executors, administrators and anyone else who may claim on my behalf, not to sue. I understand and agree to permit event officials to authorize emergency
treatment for me or for my pet at my cost. Any decision to use emergency treatment shall be made in the sole discretion
of the DRHS, its assigns or agents, or the City or County of Dubuque. I also understand and agree to permit the sponsors
of this event to use, for publicity or promotional purposes, my name and pictures of me and/or my pet without liability or
obligation to me.
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
Participant Full Name (please print): _______________________________________________
Participant Signature:__________________________________________ Date: ___________
Dubuque Regional Humane Society
563.582.6766
l
4242 Chavenelle Road l Dubuque IA 52002
www.dbqhumane.org
PLEDGE AMT. PHONE #
qCash qCheck
Complete separate pledge form, or
collect pledges online. Registration fee
counts toward your total dollars raised.
Free t-shirt if registration is received by
May 8.
*Signature of parent or legal guardian_____________________________ Date: ___________
*Any entry from someone under 18 years of age will only be accepted with his or her signature
and the signature of the individual’s parent or legal guardian.
Walk & Activities: 9 AM to Noon
qCash qCheck
qCredit Card
SUBTOTAL (this page)
CONTINUED ON PAGE 2
22nd
Dubuque Regional Humane Society’s
Annual Strut Your Mutt - Pledge Form - Page 2
SPONSOR NAME
PLEDGE AMT. PHONE #
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
qCash qCheck
qCredit Card
SUBTOTAL (this page)
Internal Use Only
Amount Received
Date
TOTAL AMOUNT
RAISED (both pages)
Verified by
PLEDGES ARE TAX DEDUCTIBLE! Print as many pledge pages as you need. All pledge money may be handed in
before walk day, or on the morning of May 16. Make checks payable to the Dubuque Regional Humane Society. Your
sponsors can make credit card donations online on the Strut Your Mutt page at www.dbqhumane.org. Choose the
“Click Here to Donate Online” button. Questions? Call Ann Lorenz at 563-556-5324, or email [email protected].
Dubuque Regional Humane Society w 4242 Chavenelle Rd. w Dubuque, IA 52002 w 563-582-6766
Dubuque Regional Humane Society’s
22nd Annual Strut Your Mutt
Saturday, May 16, 2015
Team Registration Form
The team with the most members will win a prize. Turn in this form at registration for a
chance to win! Registration is from 8 to 9 AM. Walk and activities: 9 AM to Noon.
TEAM NAME_________________________________________________________________
TOTAL NUMBER OF TEAM MEMBERS ___________________________
COMPANY NAME (if applicable)________________________________________________
LIST OF TEAM MEMBER NAMES:
1. ___________________________
12. ___________________________
2. ___________________________
13. ___________________________
3. ___________________________
14. ___________________________
4. ___________________________
15. ___________________________
5. ___________________________
16. ___________________________
6. ___________________________
17. ___________________________
7. ___________________________
18. ___________________________
8. ___________________________
19. ___________________________
9. ___________________________
20. ___________________________
10. ___________________________
21. ___________________________
11. ___________________________
22. ___________________________
Questions? Call Ann Lorenz at 563-556-5324, or email [email protected].
Dubuque Regional Humane Society w 4242 Chavenelle Road
Dubuque, IA 52002 w 563-582-6766