Pet Registration "*" indicates required fields Step 1 of 3 33% Owner InformationOwner Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Pet InformationHow Many Pets Are You Registering?*12345Pet Name* Pet Type*DogCatSex*MaleFemalePet Name* Pet Type*DogCatSex*MaleFemalePet Name* Pet Type*DogCatSex*MaleFemalePet Name* Pet Type*DogCatSex*MaleFemalePet Name* Pet Type*DogCatSex*MaleFemale Waiver of Liability*I give consent for my pet(s) to be vaccinated/microchipped/tested (Services) by the Humane Society of Bay County (HSBC) and acknowledge that such Services do not constitute complete health care. It is essential that my pet receive a yearly physical examination from a veterinarian. I further represent that my pet is in good health, has no sign of disease and is not allergic to vaccines. I accept full responsibility for any problems or illnesses arising from Services received. I Understand and AgreeI understand that receiving Services may cause unexpected reactions in pets. I agree to accept all risks of Services preformed and personally accept both legal and financial responsibility for all charges incurred because of such risks. I accept that it is my responsibility to seek emergency care as needed by a licensed veterinarian should complications arise following Services. I understand that any additional treatment may incur expense on my part.*I understand that receiving Services may cause unexpected reactions in pets. I agree to accept all risks of Services preformed and personally accept both legal and financial responsibility for all charges incurred because of such risks. I accept that it is my responsibility to seek emergency care as needed by a licensed veterinarian should complications arise following Services. I understand that any additional treatment may incur expense on my part. I Understand and AgreeI agree to indemnify and hold harmless the HSBC, its Directors, Officers, Agents, and Employees from and against any and all loss, damage, claims, liability, costs and expense, of any nature whatsoever, including without limitations, medical expenses, attorney’s fees, and disbursements, arising from or occasioned by any Services administered by HSBC.*I agree to indemnify and hold harmless the HSBC, its Directors, Officers, Agents, and Employees from and against any and all loss, damage, claims, liability, costs and expense, of any nature whatsoever, including without limitations, medical expenses, attorney’s fees, and disbursements, arising from or occasioned by any Services administered by HSBC. I Understand and AgreeI understand that Services received do not represent a physical examination or evaluation of the current health of my pet(s), that no vaccination offers 100% protection, and that testing could result in a false positive/negative.*I understand that Services received do not represent a physical examination or evaluation of the current health of my pet(s), that no vaccination offers 100% protection, and that testing could result in a false positive/negative. I Understand and AgreeBy typing my name below, I am confirming that I have read, understand, accept, and agree to be bound by the above conditions.*By typing my name below, I am confirming that I have read, understand, accept, and agree to be bound by the above conditions. FULL NAME Today's Date* Month Day Year CAPTCHANameThis field is for validation purposes and should be left unchanged.
