Northern Illinois Samoyed Assistance, Inc. Proudly Presents

Northern Illinois Samoyed Assistance, Inc. Proudly Presents
Sam O Rama
Old Fashioned Picnic
Sunday, September 29, 2013
Registration Form Packet
Activities
Parade of Diamonds
Parade of Champions
Blessing of the Animals
Merchandise Booth
Rescue Booth
Misc Games
K-9 Costume Contest
Buffet Items
Burgers
The largest Samoyed Event in the Midwest!
Hot Dogs
Fried Chicken
Baked Beans
Corn-on-the-cob
Cole Slaw
Potato Salad
Arizona Salad
Potato Chips
Parade of Adopted Samoyeds Registration Form
Check one:
[ ] 2012—2013 Champions
(Samoyeds adopted since last year and adopted Samoyeds attending for the first time)
[ ] Alumni Champions (1995 –2013)
(Samoyeds who already have their “I’m Adopted” scarves. There will be a group recognition
and yearly ovals will be available at the registration booth)
Fresh Fruit Salad
Deviled Eggs
Name: __________________________________________________ Year of adoption: _________
Brownies
Samoyeds name: ______________________________________________ Current age: _________
Cupcakes
Beverages
Shelter or group adopted from: _______________________________________________________
&
What you love most about your Samoyed: ______________________________________________
NISA’s Special
Celebration Cake
________________________________________________________________________________
________________________________________________________________________________
Sam O Rama Special
ATTENTION: This years location, Grove #4
North:
94 South to 90 West (Rockford). Exit at Arlington Heights Road
and turn left (South) to Higgins Road. Turn right on Higgins
(West) to Busse Woods on the right side of road. It’s the second
drive way on the right (North) side of Higgins. ***Grove
number 4.
Right Here
at Grove
number 4
South:
294 North to 90 West (Rockford) exit at Arlington Heights Road.
Turn left (South) to Higgins Road and turn right (West) to Busse
Woods entrance.
West
55 or 88 to 355 North. Exit at Higgins near Woodfield Mall. Turn
right (East) to the SECOND drive way on the left (North side of
Higgins) Busse Woods entrance.
90 East to Arlington Heights Road exit. At the light turn right
(South) to Higgins Road and turn right again (West) to Busse
Woods entrance.
East
Any West bound main road that connects to Arlington Heights
Road (North/South road) Higgins runs East/West. To Elk Grove
area.
***Between Arlington Heights Road and Rt. 53 on Higgins***
There are only three entrances to groves. Grove 4 is the
SECOND one on the North side.
Hotels and Restaurants Near the Picnic Site
Please be sure to ask if dogs are welcome
Red Roof Inn
22 W Algonquin Rd
Arlington Hts. (847-228-6650)
Motel 6
441 W Algonquin Rd
Arlington Heights (847-806-1230)
Doubletree
75 W Algonquin
Arlington Hts. (847-364-7600)
Amerisuites
2111 S Arlington Heights
Arlington Heights (847-956-1400)
Holiday Inn (Restaurant on site)
3405 Algonquin
Rolling Meadows (847-259-5000)
Courtyard by Marriott
100 W Algonquin Rd
Arlington Heights (847-437-3344)
Fast Food and Restaurants on Algonquin Road and Golf Road
McDonalds
Burger King
Taco Bell
Oberwise Ice Cream
Panera Bread
Ritzy's
Russel's Bar-b-que
I-Hop
AppleBees
Pre-registration form for NISA’s Sam-O-Rama
Picnic Fundraiser, September 29, 2013
PicnicBuffet available 12:30 to 2:30
Children ages 5 and under no charge
Please Print
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: _____________________________________ State: ________________ Zip: ____________
Phone: _______________________ E-mail address: _____________________________________
I hereby grant full permission to any and all of the foregoing to use my name, my pet's name, and our likenesses in any broadcast,
telecast, video or print media report or advertising of the event without compensation.
All participants Signature and date
Parent or Guardian's Signatures & date (if under 18)
Total Adult Meals:
$ _________
Junior meals (ages 6-12): __ __@ $ 8.00 each
Total Junior Meals:
$ _________
Raffle Table Tickets _____ @ 6 for $5
Total Tickets:
$ _________
Grand Total: $ ________
How many Samoyeds are you bringing?
________
**Please bring water and a bowl for your Fur-Friend**
Circle payment preference:
MASTER CARD
VISA
DISCOVER CARD
Name on card: _______________________________ Acct # ____________________________
Expiration date: _______________ 3-digit CVC # on back of card: _________
Mail ALL forms (and a check if applicable, payable to NISA)
postmarked by September 15, 2013 to:
NISA Picnic
c/o Donna Sharik
8408 Balder Drive
Cary, IL. 60013-3008
SECTION
Adult meals: __ __@ $ 15.00 each
CHECK# ________
PULL OUT
Pursuant to my participation in Sam O Rama to be held on the 29th day of September, 2013 at Busse Woods, Grove number 4, I
hereby indemnify and hold harmless Northern Illinois Samoyed Assistance, Inc and its officers, agents, officials, employees, volunteers,
representatives, and the Cook County Forest Preserve and its officers, agents, officials, employees, volunteers representatives, and all
sponsors and participants for any and all claims which may arise from my family’s participation in the event including, but not limited
to, injury, loss of property, or any other claim, whether known or unknown, arising from my participation, my family’s and my pet's
participation. I further waive all rights and remedies that I, my family or my personal representatives, heirs, executors, administrators,
agents and assigns, may have against said parties regarding any and all claims, causes of action, or other legal remedies including those
related to negligent acts or omissions. I further acknowledge that I have read and understand this Indemnification and Hold Harmless
Agreement and affix my signature hereto of my own free will.
Sam O Rama Special Insert
Sam-O-Rama Information Section
Memories from years past...
NONPROFIT ORGANIZATION
U.S. POSTAGE
PAID
PALATINE, IL
PERMIT NO. 00634
Northern Illinois Samoyed Assistance, Inc
Inc Box 218
P.O.
P.O. Box 218
Arlington
Heights, IL 60006-0218
Arlington Heights, IL 60006-0218
Rescue Hotline: 847-255-4815
Fax: 847-392-5000
Email: rescueasammy@aol.com
Recognized Affiliate of
Endorsed by the SCA
www.samoyedrescue.org
Your membership provides HOPE to a HOMELESS Samoyed!!!!!
P.S. - Do you know how much water your
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Every Samoyed saved, every Samoyed
adopted, every event and every step
forward is achieved through TEAM work.
Be it placing a stamp on the envelope or
delivering a Samoyed to it’s new family,
we all work toward the same goal and the
thrill of success is shared by all.
To insure NISA’s future, get involved!
Printing services donated by:
Allegra Print & Imaging - 510 East Northwest Highway - Palatine, Illinois 60074
Phone: (847) 963-0000 - Fax: (847) 963-0001 - E-Mail: info@allegrapalatine.net