WDA JUNIOR SPORTS PROGRAM VERIFICATION FORM


Date:_____________ Name of Event Club: __________________________

Circle One:                               Club Event                  Regional Event

Event Secretary:_______________________________________________

Junior Handler Name: ____________________________Age: ___________

Address: _____________________________________________________

City:______________________________ State: _______  Zip:__________

Phone: ___________________ E-mail:_____________________________

Parent / Legal Guardian: ___________________ WDA Member #: _______

Parent or Guardian Signature: ____________________________________

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                                              TRIAL INFORMATION  (please circle title)

BH   AD  SCH1  SCH2  SCH3  FH1  FH2  TR1  TR2  TR3  OB1  OB2   OB3   SCHA

Dog's Name: ___________________________________________________

Registration #:______________________Tattoo #: ____________________

Owner's Name: _________________________________________________

Owner's Address: _______________________________________________
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Trial Secretary Signature: _________________________________________

Junior Handler Signature: _________________________________________

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Please use 1 form for each dog. Mail completed forms to the Junior Chairperson:

                       Pat Kuehn     8 Cooksboro Rd.  Troy, NY  12182