Dog Obedience Club of Hollywood Licensed by the American Kennel Club

Transcription

1 Dog Obedience Club of Hollywood c/o Jenny Cronin 3645 Dorrit Ave Boynton Beach, FL Event Number: , & ENTRIES OPEN Saturday, November 7th, 2015 at 8:00 am Entry method is First Received ENTRIES CLOSE Thursday, December 24th, 2015 at 6:00 pm At the trial secretary's address after which time the entries cannot be accepted, canceled, altered or substituted except as provided for in Chapter 11, section 6 of the Dog Show Rules. Premium List AKC ALL-BREED AGILITY TRIALS 3 days of Regular and Preferred Standard and Jumpers with Weaves Titling Classes 1 day of FAST Titling Classes 2 days of Time 2 Beat 1 day of Premier Standard and Premier JWW This Event is Accepting Entries for Mixed Breed Dogs Listed in the AKC Canine Partners Program Dog Obedience Club of Hollywood Licensed by the American Kennel Club Friday, January 8, 2016 Saturday, January 9, 2016 And Sunday, January 10, 2016 Saint Lucie Fairgrounds Adams Arena 5202 Peacock Rd Ft. Pierce, FL Under cover on packed dirt Electronic timing will be used Starting at 8:00 am until 6:00 pm LIMITED TO 330 ENTRIES PER DAY PER JUDGE JUDGE: Gregory Beck Ginger Robertson Permission has been granted by the American Kennel Club for the holding of these events under the American Kennel Club rules and regulations. James P. Crowley, Secretary

2 Agility Trial Chair Annette Smith, 6430 Harding St, Hollywood, FL Phone: Event Committee: Bob Ansell, Nancy Atkins, Jeff Greiff, Gina Reed, Beverly Skilling, Annette Smith, Joann Smith, Keith Staub, Pam Vojtas DOG OBEDIENCE CLUB OF HOLLYWOOD OFFICERS President Jeff Greiff, 1940 SW 68 th Ave, Plantation, FL Vice President Joann Smith, 3624 Forge Rd, Davie, FL Treasurer Annette Smith, 6430 Harding St, Hollywood, FL Recording Secretary Carol Ann Klein, 534 NE 94 th St, Miami Shores, FL Corresponding Secretary Kathleen Keyte, 7198 Woodmont Way, Tamarac, FL BOARD OF DIRECTORS: Nancy Atkins, Cori Gacusana, Carol Honigmann, Kristi Sachtleben VETERINARIAN ON CALL: Veterinary Emergency & Referral Center 3984 South US Hwy 1 Ft Pierce, FL Trial Information Entries: $22 for the first entry of each dog (includes $3.50 AKC recording fee). $12 for additional entries of same dog on same day (includes $3.00 AKC recording fee) accepted by mail or in person until 6:00 PM Thursday, December 24, All entries and fees for the trial must be mailed to TRIAL SECRETARY: Jenny Cronin 3645 Dorrit Ave Boynton Beach, FL (561) gogators11@aol.com MAKE CHECKS PAYABLE TO: Dog Obedience Club of Hollywood Move Ups Written requests for dogs to be moved-up to a higher class, as a result of qualifying for an agility title, will be accepted at the trial secretary's address until 6pm on Monday, January 4, 2016 and will be included in the running order. Day-to-day move-ups will be accepted, but must be into the Trial Secretary no later than the close of the preceding day s trial. Award Information VOLUNTEERS NEEDED (AND APPRECIATED!) Agility trials take a lot of work! Please give just a little bit of your time at this and any trial that you enter. If you support this club and others, the agility community can continue to provide you the opportunity to enjoy the sport you love. Remember, without volunteers, there would be no trials! There will be a volunteer raffle with some great prizes and all volunteers will receive vouchers for food or future trial entries. To volunteer, sign up online with the following link: Jka0diVTRfVlZrZUE#gid=0 Approximate Times and Counts will be added to the signup sheet after closing Scribe Timer Gate Steward Course Builder Jump Steward Leash Runner Sheet Runner Next Day Setup Crew Jobs available to help at the trial! Questions? Pam Vojtas at pam.vojtas@datacore.com Placement rosettes will be given for 1st through 4th place in each jump height in each class. Ribbons will be awarded to all dogs receiving a qualifying score. Rosettes and ribbons will only be awarded for qualifying scores. Please claim your prizes the day of the trial, as none will be mailed.

3 Notice To Exhibitors Telegraph, telephone and fax entries cannot be accepted. Entries not on Official AKC Entry Forms or Entry forms without the Agreement and Rules on the reverse side of the form are not acceptable. Unsigned Entry Forms cannot be accepted nor entries which specify any conditions as to its acceptance. Entry Forms MUST be filled out completely. Incomplete entries do not constitute a valid entry. Owners are responsible for errors in making out entry forms, whoever may make such errors, & no entry will be refunded in event of such errors or cancellation of entries after published closing date. PLEASE PRINT OR TYPE CLEARLY. Dog Obedience Club of Hollywood, Inc., the trial secretary, their agents, etc., assume no responsibility for any loss, damage, or injury sustained by exhibitors or their dogs or property, and further assume no responsibility for injury to children not under the control of their parents or guardians. IF IT IS NECESSARY TO RESCUE A DOG FROM A PARKED CAR ON THE SHOW GROUNDS, THE CLUB WILL NOT BE RESPONSIBLE OR LIABLE FOR ANY DAMAGE TO THE CAR INVOLVED. Owners or handlers entering dogs in a trial do so at their own risk and agree to assume responsibility for any damage caused by them, or by their dogs. They also agree to abide by the Rules of the American Kennel Club and the current edition of the AKC Agility Regulations. The safety of the dogs is our primary concern. By entering this trial, exhibitors acknowledge that they are familiar with the rules and regulations of this sport and that their dogs are familiar with and able to perform all the obstacles safely. It is expressly understood that exhibitors alone are responsible for the behavior of their dogs and/or children. Any exhibitor whose dogs and/or children create unnecessary disturbances or repeatedly engage in unsafe or disruptive behavior may, at the discretion of the Trial Committee, be asked to leave the trial site. In such cases, no refund of any fees paid will be made. Entry Requirements This trial is open to all dogs fifteen (15) months of age or older that are registered with the American Kennel Club or that have AKC Limited Registration, Purebred Alternative Listing/Indefinite Listing Privileges (PAL/ILP) or an AKC Canine Partners listing number, or approved Foundation Stock Service (FSS) breeds. Dogs should be physically sound. Dogs that are blind or deaf shall not be eligible, and neither are bitches in season, aggressive dogs, or dogs suffering from any deformity, injury, or illness which may affect the dog s physical or mental performance. No dog shall compete if it is taped or bandaged in any way or has anything attached to it for medical purposes. Refer to Chapter 2 of the Registration and Discipline Rules for the listing of register able breeds and mixed breeds that may participate. Puppies under four months of age are strictly prohibited from the trial grounds. Mixed breed dogs that have been listed with AKC Canine Partners may participate provided their listing number has been recorded on the entry form and the trial-giving club is offering the optional mixed breed classes. Exhibitor Information The Regulations for Agility Trials are available on-line at For copies of the Regulations, write the AKC, 8051 Arco Dr, Suite 100, Raleigh, NC or call Refunds Entry fee minus $10.00 per day entered will be refunded for bitches that come in season after the close of the trail. The Trial Secretary must receive written notification by 9:00 am the day of the trial. Entry fee will not be refunded in the event that the dog is absent, disqualified, excused, or barred from competition by action of the Trial Committee or if the trial cannot open or be completed by reason of civil disturbances, fire, or any other cause beyond the control of the organizing committee. A $20.00 service fee will be assessed to all returned checks. Premium is available online at AVMA Statement Exhibitors should follow their veterinarian s recommendations to assure their dogs are free of internal and external parasites, any communicable diseases, and have appropriate vaccinations. Maximum Entries Per Envelope (For All Limited Trials) A maximum of ten entries per envelope is allowed. Envelopes/transactions with more than the ten dog maximum shall be treated as an invalid entry and shall be returned to the sender. If necessary, a draw for an alternate s list will be held from the remaining entries after limits have been reached. First Received, Hand Delivery Paper entries received within 24 hrs of the opening date and time must: 1) include postage or be metered; 2) be delivered by a multi-state or multi-national postal or carrier service, including but not limited to USPS, FedEx, UPS and DHL. If above conditions are not met, the entries are not valid and must be returned to the sender. Course Familiarization And Warm-Ups The walk-through is restricted to handlers entered only in that class. No course Familiarization. A warm-up area, consisting of a regulation agility jump will be provided. Vendor Information For information and reservations, contact: Annette Smith (954) agilitydocoh@aol.com Exhibitors are responsible for picking up after their own dogs. Please help us keep this site and motel grounds clean!

4 Judging Panel Gregory Beck, P.O. Box 72600, Durham, NC Ginger Robertson, 7 W Back St, Savannah, GA RING 1 RING 2 FRIDAY TENTATIVE SCHDULE SATURDAY (TALL TO SMALL) SUNDAY GINGER ROBERTSON GINGER ROBERTSON GREGORY BECK PREMIER STANDARD T2B T2B (20-26)* EX/M STANDARD EX/M STANDARD EX/M STANDARD OPEN STANDARD OPEN STANDARD OPEN STANDARD NOVICE STANDARD NOVICE STANDARD NOVICE STANDARD FRIDAY SATURDAY (TALL TO SMALL) SUNDAY GREGORY BECK GREGORY BECK GINGER ROBERTSON EX/M FAST NOVICE JWW *T2B (4-16) IN RING 1 OPEN FAST OPEN JWW NOVICE JWW NOVICE FAST EX/M JWW OPEN JWW NOVICE JWW PREMIER JWW EX/M JWW OPEN JWW EX/M JWW In Novice, B teams will run first in running order, then A teams. Preferred teams will run with appropriate level and will follow dogs jumping same height. Ring 2 will have a delayed start each day. Exact starting times for both rings will be in your final confirmation. *Ginger Robertson will start judging Time2Beat (4: - 16 ) in Ring 1 on Sunday. Ring 2 will begin when Ms. Robertson has finished in Ring 1. Remember, agility is a fun sport. Any exhibitor showing unsportsman-like conduct or mistreating a dog will be brought before a bench committee. Please visit our vendors! Pix n Pages will be available for action shots and portraits. Site Information: All classes will be held under cover on clay/dirt in rings of 100 x 100. There is plenty of shade near the rings. Crates may be set up around the rings in designated areas 10 ft from the ring fencing and left overnight, but exhibitors do so at their own risk. Please do not block the aisles! We will be using Electronic Timing. Ring Setup will begin Thursday at 3pm. The arena will be open until approximately 6pm. No one will be allowed to setup prior to ring setup completion. **** EVERYONE - IF YOU ARRIVE EARLIER THAN THE COMPLETION OF RING SETUP, PLEASE LEND A HAND AND HELP OUR VOLUNTEERS SO YOU CAN SET UP EARLIER!!!! **** The arena will be open daily at 6:30am. Competition begins each day at 8am. Classes Offered Standard Novice A * Standard Novice B * Standard Open * Standard Excellent * Standard Master * Premier Standard * JWW Novice A * JWW Novice B * JWW Open * JWW Excellent * JWW Master * Premier JWW * FAST Novice A * FAST Novice B * FAST Open * FAST Excellent * FAST Master * Time2Beat * Standard Novice Preferred * Standard Open Preferred * Standard Excellent Preferred * Standard Master Preferred * Premier Standard Preferred * JWW Novice Preferred * JWW Open Preferred * JWW Excellent Preferred * JWW Master Preferred * Premier JWW Preferred * FAST Novice Preferred * FAST Open Preferred * FAST Excellent Preferred * FAST Master Preferred * Time2Beat Preferred Height Divisions Owners are responsible for entering the proper height division. Regular Preferred for dogs 11 inches & under at the withers 8 inches 4 inches for dogs 14 inches & under at the withers 12 inches 8 inches for dogs 18 inches & under at the wither 16 inches 12 inches for dogs 22 inches & under at the wither 20 inches 16 inches for dogs over 22 inches 24 inches 20 inches For any dog at owners discretion 26 inches N/A NEW Simplified Jump Height Card Process When filling out the entry form, there is section on the form for exhibitors to designate whether your dog your dog needs to be measured. Please check the appropriate box so that the Trial Secretary knows whether to include your dog on the Dogs To Be Measured List. It is no longer required that you submit a copy of your dog s jump height card with your entry form or show it during day of show check-in

5 Directions to Show Site: From West: Take State Road 70 east (Okeechobee Rd), turn right onto Peacock Rd. If you pass over the pedestrian overpass, you have gone too far. Turn left into SLC Fairgrounds rear entrance From I-95: Take exit #129, State Road 70 (Okeechobee Rd), go west 6.5 miles. Turn left on Peacock Rd, just past the pedestrian overpass. Turn left into SLC Fairgrounds rear entrance. From FL Turnpike: Take exit #152, State Road 70 (Okeechobee Rd), go west 6 miles. Turn left on Peacock Rd, just past the pedestrian overpass. Turn left into SLC Fairgrounds rear entrance. HOTELS THAT ACCEPT DOGS (Please reconfirm that dogs are welcome) Holiday Inn Express (772) Okeechobee Rd, Fort Pierce, Florida Quality Inn (772) Reynolds Dr, Fort Pierce, Florida, (No size restrictions) La Quinta Inn (772) Crossroads Pkwy, Fort Pierce, Florida, Fairfield Inn & Suites (772) Metal Dr, Fort Pierce, Florida, ABSOLUTELY NO BATHING OF DOGS IN ROOM; PLEASE CLEAN UP AFTER YOUR DOG DOCOH Agility Trial Camping & RV Reservation Form Friday, January 8 through Sunday, January 10, 2016 St Lucie County Fairgrounds, 5202 Peacock Rd, Ft Pierce, FL All RV Spots will be reserved Please do not arrive prior to Noon on Thursday, January 7, Note: There are limited 50 amp spots. Several 50 amp spots DO NOT have sewer but there is a dump station available on site. Reservations will not be accepted prior to November 7, 2015 (trial opening date). Please contact RV Coordinator if you send your reservation after the trial closing date to ensure you have a spot. All reservations will receive an confirmation. 30/50 amp RV hook-up with water and electric. (Not all spots have sewer but there is a dump station on site.) $32.00 per night includes tax. Name: Address: City: State: Zip: Cell phone: Emergency phone: Mfg & Model of RV: Length: License #: State: I Prefer (Circle one): 50 Amp/ 30 Amp Site # Arrival Date Departure Date: Total nights: Total enclosed ($32 x # of nights): *Dumping of gray/black water is NOT allowed and could be cause for expulsion for site. *Campers/RV Do not have the authority to hard wire anything into the electrical system *No refunds will be issued unless written notice is received prior to the start of the agility trial. Please complete this reservation form and mail with check payable to DOCOH: Nancy Atkins, DOCOH RV Coordinator 560 NW 73 rd Ave, Plantation, FL Questions? Nancy (nancydash@yahoo.com) or call

6 INTRODUCING PREMIER STANDARD on FRIDAY And PREMIER JUMPERS WITH WEAVES on SATURDAY NEW Chapter 11 Premier Class Section 1. Purpose. These optional titling classes are designed to challenge dogs and handlers at an increased speed and skill level above those set for the Master level classes. Handlers/dogs will need to negotiate courses that require varied approach angles, spacing, and obstacle discriminations to be successful in these classes. These classes are offered as separate titling tracks and are not part of the MACH/PACH Championships. Premier may be offered once per day as an additional class or classes. Clubs may, but are not required to offer Premier Standard and Premier Jumpers with Weaves on the same day. Section 2. Eligibility. Dogs with an AX title are eligible to enter Premier Standard Regular. Dogs with an AX or AXP title are eligible to enter Premier Standard Preferred. Dogs with an AXJ title are eligible to enter Premier Jumpers with Weaves Regular. Dogs with an AXJ or AJP title are eligible to enter Premier Jumpers with Weaves Preferred. Dogs with Regular titles may crossover to the Premier Preferred level as noted above Section 3. Performance Standards Minimum allowable score required to qualify = 100. The course must be completed before the dog reaches the Maximum Course Time Additional Non-Qualifying faults (beyond those listed in Chapter 5, Sections 5 and 6). -Any Course Fault Maximum Course Times (MCT) Premier Standard Regular: - 55 seconds for the 20 and 26 inch Regular jump heights seconds for the 16 and 24 inch Regular jump heights seconds for the 8 and 12 inch Regular jump heights. Preferred: - 60 seconds for 16 inch Preferred jump height seconds for 12 and 20 inch Preferred jump heights seconds for 4 and 8 inch Preferred jump heights. Premier Jumpers With Weaves Regular: - 40 seconds for 20 and 26 inch Regular jump heights seconds for the 16 and 24 inch Regular jump heights seconds for the 8 and 12 inch Regular jump heights. Preferred: - 45 seconds for 16 inch Preferred jump height seconds for 12 and 20 inch Preferred jump heights seconds for 4 and 8 inch Preferred jump heights. Note: For timing purposes all Premier Jumpers With Weaves classes may have timer set for MCT of 53 seconds. Minimum Obstacle Requirements: Quantity = Obstacles required, allowed, and not allowed will be the same as the Master level courses as noted in Chapter 6, Section 5 for Standard; and Chapter 7, Section 5 for Jumpers With Weaves, except that both classes will have a maximum of three tunnel passes and Standard will not have a table. In both classes the viaduct jumps, as described in Chapter 13, Section 9, can be substituted for the panel jump or a spread jump, as long as the viaduct jump can be set for all heights. Section 4. Obstacle and Jump Positions. Shall generally follow the requirements set forth in Chapter 4, Section 4, with the following exceptions: - A Distance of feet between two obstacles may be approved up to two times on a course. - Distances of greater than 30 feet between obstacles may be approved to allow for turns between obstacles as necessary. - There may be one bi-directional tunnel or bar/single bar jump on the course. Section 5. Approach Angles. Shall generally follow what is stated in Chapter 4, Section 5, except as detailed in the AKC Agility Judges Guidelines for the Premier Class. Section 6. Titles. To earn the Premier Agility Dog (PAD), Premier Agility Dog Preferred (PADP), Premier Jumpers Dog (PJD) or Premier Jumpers Dog Preferred (PJDP) titles, a dog must earn 25 qualifying scores with five qualifying scores earned for placing in the top 25% of the dogs that competed in their jump height. Dogs that are absent or withdrawn will not count toward the number of dogs competing in the jump height. The 25% calculation will be rounded to determine the number of 25% placements in each jump height. In the case of a tie both dogs will receive the top 25% placement. If a class has two or three dogs competing, the 1st place dog will be awarded a top 25% placement qualifying score If only one dog competes in the jump height, there will be no top 25% placement earned in that jump height. Lifetime Achievement titles (bronze, silver, gold and century) will be awarded for each additional 25 qualifying scores earned in the Premier class. Note: For timing purposes all Premier Standard classes may have timer set for MCT of 70 seconds.

7 OFFICIAL AMERICAN KENNEL CLUB AGILITY ENTRY FORM Dog Obedience Club of Hollywood Opens: November 7, 2015 Closes: December 24, 2015 Day 1: 01/08/16 STD JWW FAST Premier Std Day 2: 01/9/16 STD JWW T2B Premier Jww Day 3: 01/10/16 STD JWW T2B Daily Entry Fee: 1st run $22; $12 each additional run Make checks payable to: DOCOH; Mail to: Jenny Cronin, 3645 Dorrit Ave, Boynton Beach, FL IMPORTANT: Carefully read instructions before filling out! ENTRY FEE ENCLOSED Choose Either Regular OR Preferred Classes Circle one jump height, and circle class selections :: Only one selection per class (STD, JWW, FAST, T2B) REGULAR Classes STD Nov A Nov B Open Exc Master Premier JWW Nov A Nov B Open Exc Master Premier FAST Nov A Nov B Open Exc Master T2B T2B This Dog Needs To Be Measured Yes No SEX PREFERRED Classes STD NovP OpenP ExcP MasterP PremierP JWW NovP OpenP ExcP MasterP PremierP FAST NovP OpenP T2B T2BP ExcP MasterP HEIGHT AT WITHERS BREED VARIETY CALL NAME AKC NAME (INCLUDE AKC TITLES ONLY) AKC NO ILP NO. PAL NO. FOREIGN REG. NO & COUNTRY BREEDER SIRE DAM ACTUAL OWNERS OWNERS ADDRESS CITY, STATE ZIP + 4 HANDLER Enter Complete Registration # below DATE OF BIRTH PLACE OF BIRTH (LIST COUNTRY) NEW ADDRESS ENTER JR. HANDLER # if applicable Exhibitor or owner MUST sign on the signature line beneath the instructions. AKC Rules, Regulations, Policies and Guidelines are available on the American Kennel Club Web site, AGREEMENT I (we) agree that the club holding this event has the right to refuse entry for cause which the club shall deem sufficient. In consideration of the acceptance of this entry and of the holding of this event and of the opportunity to have the dog judged and to win prizes, ribbons, or trophies, I (we) agree to hold the AKC, the event-giving club, their members, directors, governors, officers, agents, superintendents or event secretary and the owner and/or lessor of the premises and any provider of services that are necessary to hold this event and any employees or volunteers of the aforementioned parties, and any AKC approved judge, judging at this event, harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or about the event premises or grounds or near any entrance thereto, and I (we) personally assume all responsibility and liability for any such claim; and I (we) further agree to hold the aforementioned pa rties harmless from any claim for loss, injury or damage to this dog. Additionally, I (we) hereby assume the sole responsibility for and agree to indemnify, defend, and save the aforementioned pa rties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting therefrom, sustained by a ny person or persons, including myself (ourselves), or on account of damage to property, arising out of or in consequence of my (our) participation in this event, however such, injuries, death or property damage may be caused, and whether or not the same may have been caused or may be alleged to have been caused by negligence of the aforementioned parties or any of their employees or agents, or any other persons. I (WE) AGREE THAT ANY CAUSE OF ACTION, CONTROVERSY OR CLAIM ARISING OUT OF OR RELATED TO THE ENTRY, EXHIBITION OR ATTENDANCE AT THE EVENT BETWEEN THE AKC AND THE EVENT-GIVING CLUB (UNLESS OTHERWISE STATED IN ITS PREMIUM LIST) AND MYSELF (OURSELVES) OR AS TO THE CONSTRUCTION, INTREPRETATION AND EFFECT OF THIS AGREEMENT SHALL BE SETTLED BY ARBITRATION PURSUANT TO THE APPLICABLE RULES OF THE AMERICAN ARBITRATION ASSOCIATION. HOWEVER, PRIOR TO ARBITRATION ALL APPLICABLE AKC BYLAWS, RULES, REGULATIONS AND PROCEDURES MUST FIRST BE FOLLOWED AS SET FORTH IN THE AKC CHARTER AND BYLAWS, RULES, REGULATIONS, PUBLISHED POLICIES AND GUIDELINES. INSTRUCTIONS Handlers may opt to enter in a higher height division for all Regular titling classes, but not in a division lower than their proper height division. Dogs entered in the Preferred classes must compete at the required jump height and may not compete in a jump height division higher or lower than their proper height division. All dogs that have not been officially measured for an Agility Jump Height Card may still compete; however, they must be measured by a Judge of record, an Agility Field Representative, or a Volunteer Measuring Official, prior to running. If measured by the Judge of record, that measurement will be valid for this trial or back-to-back trials only. If a measurement is necessary, it is the exhibitor's responsibility to have their dog(s) measured prior to running. Dogs listed in the AKC Canine Partners SM program may be eligible to enter all-breed AKC agility trials at the club s option. These dogs should be listed as All American Dog and must include their AKC number on the entry form and check the AKC No. box. Junior Handlers should enter their Junior Handler number on the front of this form. Should you not have your Junior Handler number, it may be obtained from the American Kennel Club (919) If the Junior Handler is not the owner of the dog identified on the face of this form, what is the relationship of the Junior Handler to the Owner? I CERTIFY that I am the actual owner of the dog, or that I am the duly authorized agent of the actual owner whose name I have entered above. In consideration of the acceptance of this entry, I (we) agree to abide by the rules and regulations of the Am erican Kennel Club in effect at the time of this event, and by any additional rules and regulations appearing in the premium list for this event, and further agree to be bound by the Agreement printed on the reverse side of this entry form. I (we) certify and re present that the dog entered is not a hazard to persons or other dogs. This entry is submitted for acceptance on the forgoing representation and agreement. I (we) agree to conduct myself (ourselves) in accordance with all such Rules and Regulations (including all provisions applying to discipline) and to abide by any decisions made in accord with them. SIGNATURE of owner or his agent duly authorized to make this entry. SIGN HERE X Telephone Number: Address: In Case of Emergency - Name: Phone #: New