Name of Applicant *

First Name

Last Name

Name Applicant #2 (Household Membership)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

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Cell Phone Applicant #1 *

(###)

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Cell Phone Applicant #2 (Household)

(###)

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Type of Membership *

Individual

Household

Name of FSRC Member who is sponsoring your application *

First Name

Last Name

How would you like to help the club? *

Our club depends upon the volunteer efforts of our members. How can you help our club thrive? Select as many as you like.

Help with Training Days?

Help with Hunt Tests/Field Trials?

Help with Administrative Tasks?

Insurance Waiver - Assent and Release *

* Permission is hereby granted to the undersigned participant to attend, participate, and work as requested on the grounds as selected by FSRC. * The participant agrees to be responsible for his/her own safety while present in any and all FSRC events and the lands selected. This permit covers only the lands selected by FSRC and the participant agrees to respect the land of adjoining landowners. * In light of the foregoing and in consideration of being a willing participant with permission to participate and attend the event(s) of FSRC, the undersigned hereby WAIVE any and all claims of any kind whatsoever including, but not limited to, claims for bodily injury, economic loss and property damage while present or engaged in any event conducted by FSRC, which the participant may sustain while present at any event. The participant agrees, jointly and severally, to the terms of the Agreement and, in addition, agrees to release, indemnify, and hold harmless FSRC, it's officers, its corporate officers, employees, his/her heirs, personal representatives, and assigns from any loss, claim, or liability associated with FSRC, its condition and the conduct of other participants at any event conducted by FSRC and/or the conduct of any other person or persons on or about any event, including, but not limited to, claims for bodily injury, economic loss and property damage, which the participant may cause to others of which others may sustain or cause while present at said events or engaged in any event under this permit and agree to accept same for the purpose described herein as is, with all faults that may exist thereon.

I/we have read the above statements and hereby make application to the First State Retriever Club. I/we agree to uphold the objectives of the Club and abide by its Constitution and By-Laws and the Rules of the American Kennel Club, and are in agreement with the terms of the insurance waiver. By signing below, I/we attest that I/we am/are in good standing with the AKC and any other AKC clubs I/we am/are a member of and additionally have not been santioned or had a membership revoked by the AKC or another AKC club.