Sunday, April 23, 2017, 9:00 AM
Boyce Park Tanglewood Shelter, Plum, PA
$20 – One Participant/One Pet, $5 Each Additional Pet

Return entirely completed form to
Friends of Jupiter Pet Walk, P.O. Box 14006, Pittsburgh, PA 15239
Make checks payable to: Northcentral Maltese Rescue, Inc.

                          * You can print this form from your computer and send it in with your check
                          * You can copy this form and paste in a Word document, fill it out and email it 
                                   to or pay through PayPal
                          * Payment can be made via PayPal but must be made before you send in this 
    Registration Form. Entry will not be accepted until payment is made
                          * This link will take you to the PayPal Registration Payment Page

Walker Information

       Name: __________________________________________________________________________

       Address: ________________________________________________________________________

       City: ________________________________ State: ________ Zip: _________________________

       Phone: ________________________ Email: ___________________________________________

Pet Information

       Pet Name: _______________________ Breed: ____________________ Age: _____

​       Pet Name: _______________________ Breed: ____________________ Age: _____

       Pet Name: _______________________ Breed: ____________________ Age: _____

       ______ I will be walking in Memory or in Honor of my pet that cannot be here today (circle one)
       ______ I am unable to walk, but here is my donation in support of this special cause

         Waiver: In consideration of my signing this agreement, I hereby, for heirs, my administrators and myself, assume any and all risks, which may 
       be associated with this event. I waive and release any and all rights for damage which I may have against the organizers, Northcentral Maltese, 
       Inc., and any others connected with this event, their representatives, successors and assigns for any and all injuries or damages of any kind 
       whatsoever suffered by me or my pet as a result of taking part in this event and any related activities. My pet has all current vaccinations as re-
       quired by law. I consent to the use of my photograph or likeness from this event for any publicity.

      Name (print): ____________________________ Signature:________________________ Date:______________

     Parent Signature if under 18: ________________________________________________ Date: ______________

    This walk is presented by NORTHCENTRAL MALTESE RESCUE, INC.
   To see Walk Details, click on link below

                       For more info on Northcentral Maltese Rescue Inc. -
                       For more info on Friends of Jupiter Pet Walk -

Click on a Link Below for More Information