ENTRY FORM (Please print legibly. Use one entry form per person.)

Circle one: Mr. Mrs. Ms. Miss Dr.

I am participating in: (circle one) 1 Mile Walk 5K Run 10K Run

First name: _______________________________________________ Middle initial: ____________

Last name:_______________________________________________________________________________

Email address: __________________________________________________________________________

Address: ____________________________________________________________ Apt # :____________

City & State: ____________________________________________________ Zip: _________________

Phone #: (circle one) Home Work Cell (_______)________________________________

How did you hear about “The Fast & The Furriest”?

Friend/Family Adopted pet from HPC TV Radio ⧠ ⧠ ⧠ ⧠

GI Independent Hastings Tribune Facebook HPC website ⧠ ⧠ ⧠ ⧠

Brochure/Poster Banner Other ⧠ ⧠__________________________________________⧠

Your gender: Male Female Your Birthdate (mo/day/yr): _______________________

Bringing your Dog? Yes No Dog’s Name: ____________________________________

$___20________Registration

$______________ Additional Pledges

$______________TOTAL AMOUNT ENCLOSED

*******Please make all checks payable to: HEARTLAND PET CONNECTION******

Participant Signature: ________________________________________________ Date:_________

FOR HPC USE ONLY

Registration CK#__________________________ Adult Child

Pledges Amount $________________________ Size:___________________

TOTAL AMOUNT ENCLOSED $________________ Sleeve: S L

OCTOBER 6 • MPH RACEWAY • HWY 6 & SHOWBOAT BLVD • HASTINGS, NE 11AM

WAIVER & RELEASETo participate in “The Fast & The Furriest”, you must sign the following Waiver and Release.By registering for Heartland Pet Connection’s “The Fast & The Furriest”, you agree to the following Waiver and Release.I understand that participating in Heartland Pet Connection’s “The Fast & The Furriest”, involves risks to me and to my pet. I assume all risks to me and my pet 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 have carefully read this Waiver and Release and agree to a global and general release of liability. I hereby waive, release and discharge Heartland Pet Connection, any organization affiliated with Heartland Pet Connection, and their respective directors, employees, volunteers and agents, event officials, and any sponsors, suppliers, independent contractors and all other individuals and entities in any way assisting or connected with this event from any and all claims, harm, and liability of whatever kind or nature whatsoever arising out of my or my pet’s participation in this event, whether or not those claims and liabilities arise as a result of negligent action or inaction by individuals or entities released by this Waiver and Release. 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 Heartland Pet Connection, its assigns or agents.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.

Signature of participant:____________________________________________Date:___________Any entry from someone under 19 years of age will only be accepted with his or her signature and the signature of the individual’s parent or legal guardian. The undersigned does represent that he or she, acting as parent or guardian of participant, has consented to the participant’s taking part in the event and has agreed individually and on behalf of participant to the terms of the waiver and release of liability set forth above.Signature of parent or legal guardian of participant under 19 years of age:

Signature of parent of legal guardian of participant under 19 years of age:

________________________________________________________________ Date: ____________________

Heartland Pet Connection • PO BOX 2162 • Hastings, NE 68902

PLEDGE FORM

• It’s easy and fun to raise

pledges! Ask friends, family and

co-workers to sponsor you.

• Make sure your first and last

name are on all pledge forms

and checks, so you’ll receive

credit for your pledges.

• Turn in your pledges either in

advance or at registration on

event day.

• The IRS has determined that

pledge donations are tax

deductible!!

PLEDGE FORM

Your Name:_____________________________________________________________________

******Make All Checks Payable to Heartland Pet Connection******

Use the memo area for Participants first and last name so they get credit!

SPONSORS NAME

STREET ADDRESS CITY, STATE, ZIP PLEDGE AMT.

EXAMPLE:

HPC Pet Lover

EXAMPLE:

1234 Labrador Lane

EXAMPLE:

Hastings NE 68901

EXAMPLE:

$50.00

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