MPWDA Summer Seminar &
NAPWDA Certification
June 7 – 11, 2010
University of Massachusetts - Amherst
REGISTRATION CHECKLIST
Before mailing your application, please verify that you have completed, signed, and included
all of the items on the following checklist. To be considered a complete application, all items
must be received no later than May 21, 2010. Be sure to make copies of all submitted
documents for your records.
1.
2.
3.
4.
5.
Application Form
Accident Waiver and Release of Liability Form to MPWDA
Release/Indemnification and Hold Harmless Form to UMass Amherst
Check made out to “MPWDA” for the amount of $225
Deadline for submission is May 21, 2010.
Please mail the above documents to:
Massachusetts Police Work Dog Association
215 South Main Street
Lanesboro, MA 01237
REFUNDS: Full refunds will be given only under the following circumstances:
(1) A request is received in writing for a refund NO LATER THAN JUNE 1 st, AND
(2) The participant’s space is filled by another individual, paid in full.
We apologize for any inconvenience but no refunds will be issued after June 1, 2010.
NOTE: To receive certification, you must either be a current NAPWDA member or must join before
attending this workshop. See www.napwda.com for complete details on how to join. Please do not
send NAPWDA membership applications or fees to the Massachusetts Police Work Dog Association.
GENERAL INFORMATION
Logistics
Handlers should expect to drive to/from the training locations and will need to provide their
own means of transportation. Handlers are responsible for their own food, water, gear, and
other necessities.
Emergency Information
A medical-veterinary safety document will be provided to every participant on the first day of
the seminar. There are both human emergency centers and emergency animal facilities in
the Amherst area as well as a paramedic level ambulance service on the campus.
Events and Other Information
This is a certification workshop and organized training seminar. This does not preclude
handlers from training or self-organizing, however training may not occur at the facilities
where testing elements are being held. Handlers are required to comply with all rules, laws,
regulations, or other constraints during the testing and will be responsible for bringing and
utilizing all required gear.
Maps will be provided and handlers are responsible for ensuring they are at the test locations
at the required times. The schedule for testing elements will be determined by the evaluators
and organizers. Handlers are responsible for all fees for failed elements as outlined in the
NAPWDA by-laws and certification document. Handlers are also responsible for providing all
prerequisite documentation to the evaluators.
Do not submit prerequisite documentation with your application.
Cost
The cost to participate is $225 per team. This will cover the instructor travel and per diem.
All meals, gear, fuel, lodging, and other expenses are the responsibility of the handler.
Handlers with multiple dogs wishing to certify should contact a seminar coordinator. A
completed application will be required for each dog and handler.
Questions and Contact Information
 For application, enrollment status, to cancel participation, or request a refund,
please contact Jim Rathbun at 413-443-4107 or SRT1228@aol.com.
 For lodging, directions to the training facility, or other logistical questions,
please contact Liana Varosky at 413-626-9997 or LVarosky@admin.umass.edu.
 All other questions may be directed to Dwane Foisy at 413-446-1654 or
mak9052@yahoo.com.
MPWDA Summer Seminar &
NAPWDA Certification
June 7 – 11, 2010
University of Massachusetts - Amherst
APPLICATION FORM
APPLICANT INFORMATION
Last Name
First Name
Contact Phone #
Email Address
Street Address
City
State
Zip Code
Emergency Contact Name
Relationship to Handler
Phone #1
Phone #2
AGENCY INFORMATION
Department
Street Address
City
Agency Phone #
Agency Fax #
State
Zip Code
CANINE INFORMATION
Name
Breed
K9 Type
K9 Ability Level
Dual Purpose
Patrol
Narcotics
Cadaver
Tracking / Trailing
Explosives
Gender
Handler Ability Level
Male
Female
Purpose of Attendance
Beginner
Beginner
Certification – NEW
Intermediate
Intermediate
Certification – RENEWAL
Advanced
Advanced
Training
I certify that all canines I bring to this seminar are
current on vaccines for rabies, kennel cough, and
DHLPP (initial): __________
June 7-11, 2010:
Age
If certifying, what areas of NAPWDA certification will
you be attempting?
MPWDA / UMASS 2010 K9 PATROL / NARCOTIC DETECTION WORKSHOP
Massachusetts Police Work Dog Association
ACCIDENT WAIVER / RELEASE OF LIABILITY FORM
Activity: K-9 Patrol / Narcotics Certification and Workshop
Date: June 7 - 11, 2010
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN THIS ACTIVITY, including by way of example and not
limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from
dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability
without fault.
I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised
to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude
my participation in this activity.
I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and
organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.
In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors,
administrators, heirs, next of kin, successors, and assigns as follows:
(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the
negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or
actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING
ENTITIES OR PERSONS: the Massachusetts Police Work Dog Association (MPWDA) and/or their directors, officers,
volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;
(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from
any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or
otherwise.
I acknowledge that MPWDA and their directors, officers, volunteers, representatives, and agents are NOT responsible for the
errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.
I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for
death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature,
weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not
limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but
are also present for volunteers.
I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness
during this activity.
I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be
used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.
Accept:
Decline:
Initials: ________
The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum
extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I CERTIFY
THAT I AM OVER 18 YEARS OF AGE. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A
CONTRACT AND I SIGN IT OF MY OWN FREE WILL.
________________________________
Student’s Signature
June 7-11, 2010:
__________________________
Student’s Name Printed
_________
Date
MPWDA / UMASS 2010 K9 PATROL / NARCOTIC DETECTION WORKSHOP
University of Massachusetts Police Department
351 Hicks Way, Dickinson Hall, Amherst, MA 01003
413-545-2121 (non-emergency)
University of Massachusetts
Release/ Indemnification and Hold Harmless Agreement
I, __________________________________, fully understand that my participation in the use of the lands
of the University of Massachusetts at Amherst (hereinafter referred to as “UMASS”) exposes me to the risk
of personal injury, death, or property damage. I hereby acknowledge that I am voluntarily participating in
this training and expressly agree to assume any such risk.
In consideration for being permitted to participate in this training, I hereby release and forever discharge
UMASS, the University of Massachusetts Police Department, the Commonwealth of Massachusetts, the
town of Amherst, the town of Hadley, the Massachusetts Police Work Dog Association, and all their
respective officers, employees, agents, and volunteers from any and all liability, claims, demands, damages,
actions or causes of action arising from or by reason of any injury to or death to me or any person, or any
damage to or loss of personal property resulting from or arising out of any accident or occurrence in
connection with my participation in the training from whatever cause, whether or not such injury, death or
damage is caused or alleged to be caused by an act or failure to act of any kind on the part of UMASS, the
University of Massachusetts Police Department, the Commonwealth of Massachusetts, the town of
Amherst, the town of Hadley, the Massachusetts Police Work Dog Association, and their respective
officers, employees, agents and volunteers or any other participants in the event.
In further consideration for being allowed to participate in the event, I hereby agree for myself, my heirs,
administrators, executors, and assigns that I shall save, indemnify, and hold harmless UMASS, the
University of Massachusetts Police Department, the Commonwealth of Massachusetts, the town of
Amherst, the town of Hadley, the Massachusetts Police Work Dog Association, and their respective
officers, employees, agents, and volunteers from any and all claims, demands, actions, or suits arising out
of or in connection with my participation in the training brought by any third party.
I have carefully read this release, indemnification and hold harmless agreement and fully understand its
contents. I am aware that it is a full release of all liability and I sign it voluntarily and with full knowledge
of its significance.
I also agree that during this training I will conduct myself in a safe and professional manner. I will not
engage in any unlawful activity that demeans or harasses another on any unlawful basis, including race,
sex, or religion. In addition I will not take part in any unlawful lewd behavior or sexual harassment as those
terms are defined by law. Any such harassment or behavior will be reported immediately to the instructor
or facilitator.
___________________________________
___________________________________
Signature
Department Name
___________________________________
___________________________________
Printed Name
Date
June 7-11, 2010:
MPWDA / UMASS 2010 K9 PATROL / NARCOTIC DETECTION WORKSHOP