Wag-A-Thon Registration

Name

First NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

We Are Walking to Support:

Pet Name:

Get family, friend and colleagues to support your 4-legged friend by securing pledges on this form! All the money raised supports Hospice of Jefferson County & Jefferson County SPCA!

Wag-A-Thon T-shirt!

All participants who raise $100 will recive a commenorative Wag-A-Thon T-shirt.

Available Packages

VIP Package

VIP Package - $60 (4 Registration Tickets + 2 Meal Vouchers)

$60.00 Quantity

Family Package

VIP Package - $60 (4 Registration Tickets + 2 Meal Vouchers)

$30.00 Quantity

Individual Registration

$10.00 Quantity

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Registration Disclaimer:

I hereby waive all claims against Hospice of Jefferson County, Inc., and the Jefferson County SPCA for any injury, illness, loss, or damage arising from my, my child’s, or my dog’s participation in the Wag‑A‑Thon. I acknowledge the risks of animals and events, agree to keep my dog leashed and under control, confirm my dog’s vaccinations are current, and will clean up after my animal. I grant permission for photos or videos of me, my child(ren), and my dog to be used for promotional purposes.

Important: Participants under age 18 must have this signed by a parent or guardian.

Participant's Signature

Guardian's Signature