2016 NAPWDA Dakota Workshop
Brookings, South Dakota
June 7, 8 and 9, 2016
Application Form
First and Last Name: ________________________________________________________________________
Street, City and Zip Code: ____________________________________________________________________
_________________________________________________________________________________________
E-Mail Address: ____________________________________________________________________________
___ Check here for NASAR SAR TECH II test only. Proceed to Release of Liability portion and sign.
Home Phone #: ______________________________ Cell Phone #: _________________________________
K9 Name: ________________________________________________
With this K9...
K9 Age: _______
____
K9 Breed: _________________________________
Comments: (Previous certifications, problems or concerns)
HRD Test
___ Tracking Test
___ Trailing Test
___ Area Search Test
___ Training Only
K9 Name: ________________________________________________
With this K9...
K9 Age: _______
____
K9 Breed: _________________________________
Comments: (Previous certifications, problems or concerns)
HRD Test
___ Tracking Test
___ Trailing Test
___ Area Search Test
___ Training Only
K9 Name: ________________________________________________
With this K9...
K9 Age: _______
____
K9 Breed: _________________________________
Comments: (Previous certifications, problems or concerns)
HRD Test
___ Tracking Test
___ Trailing Test
___ Area Search Test
___ Training Only
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.
Page 1 of 2
Release of Liability
I, the undersigned, request to participate in the 2016 NAPWDA DakotaWorkshop (here after referred to as workshop) to
be held in/around Brookings, South Dakota, June 7-9, 2016.
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.
7. If you decide to consume any alcoholic beverage during the workshop week, you do so at your own risk. If you do
drink an alcoholic beverage please do so in a responsible manner and Don’t Drink and Drive.
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 2016 NAPWDA Dakota Workshop held in/around Brookings, South Dakota, June 7-9,2016.
Print Name: ___________________________________________________
Signature of Applicant: __________________________________________
Complete form and mail to:
BCK9SAR
21289 459th Avenue
Volga, SD 57017
Page 2 of 2
Date: ________________