Meals on Wheels Rockland

Wags For Wheels Registration Form

Please fill in your information below. After you agree to the terms and press the Submit button you will be asked to make your donation to Meals on Wheels via PayPal. If you prefer to pay by check please send your completed registration form to Meals on Wheels 121 West Nyack Road, Nanuet, NY 10954, along with your check made payable to Meals on Wheels.

* All fields marked with an asterisk are required

* First Name:         * Last Name:    

* Address:         * City:         * State:         * Zip:    

* Home Phone (e.g. 845-123-4567):         Cell Phone (e.g. 845-123-4567):    

E-mail Address:    

In the event of a cancelation or postponement of the event you will be sent a notification to the email address above.


If you belong to a team then select it from the list below otherwise leave the team name as "No Team"

Team's Name:    


Dogs Participating in Walk:

    First Dog's Name:

    Second Dog's Name:

    Third Dog's Name:

    Fourth Dog's Name:

    Fifth Dog's Name:

    Sixth Dog's Name:

The $25 price is a discounted price for online registrations made prior to walk.

    Number of Dogs x $25 per dog = $
 
 
Journal Entries (Deadline May 20, 2015):

Enter the pets names that you would like to appear in the Journal:
(click the button "In Memory" or "Good Pet" next to each name)

        In Memory     Good Pet  

        In Memory     Good Pet  

        In Memory     Good Pet  

        In Memory     Good Pet  

        In Memory     Good Pet  

        In Memory     Good Pet  

    Number of Journal Entries x $10 per pet = $
 
Doggone it:

    I can't participate, but here's my donation to support
    programs and service of Meals on Wheels
$
 
Total Amount $


How did you hear about the walk?:    

All walkers must read and agree with this waiver:

In consideration of being permitted to participate in Wags for Wheels, I/we hereby assume any and all risks that might be associated with the event. I/we indemnify and hold Meals on Wheels Programs & Services of Rockland, Inc., the Town of Ramapo, the sponsors, officials, volunteers and the agents, officers, directors and employees of the foregoing parties harmless from any and all loss, liability, injury, damage or costs arising from or related to my/our participation in this event including reasonable attorney's fees and take full responsibility for my dog and any person or persons accompanying me. I/we agree to the use of any photo, film or videotape of the event for any purpose.

I agree Terms and Conditions