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 GuardianSignature:__________________________________

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                                           BREED SURVEY INFORMATION
                                     (circle protection and/or stand for each dog)

Dog's Name:  ________________________________ Protection       Stand

Registration #: _______________________  Tattoo #:______________

Owner's Name:_____________________________________________


Dog's Name: __________________________________ Protection   Stand

Registration #: _____________________  Tattoo #:_________________

Owner's Name:______________________________________________



Dog's Name: __________________________________ Protection   Stand

Registration #: ________________________  Tattoo #:______________

Owner's Name:______________________________________________
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                                      CONFORMATION SHOW INFORMATION

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______ Number of dogs in class: ______

Class__________________Placing:_______Number of dogs in class: ______

Class: _________________Placing: ______ Number of dogs in class: ______

Class: _________________Placing: ______ Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

Class: _________________Placing: ______Number of dogs in class: ______

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Show Secretary's Signature: ____________________________________

Junior Handler's Signature: ____________________________________

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Please mail form to Junior Chairperson:

                          Pat Kuehn     8 Cooksboro Rd.   Troy, NY  12182