E-Mail:
Owner/Handler Name:
Billing Address:
City:	State: Zip:
Home Phone:	Work: Cell:
1. Dog's Name:
2. Dog's Gender:	Male	Female
3. Dog's Age:	0 1 2 3 4 5 6 7 8 9+ Years	1 2 3 4 5 6 7 8 9 10 11 12 Months
4. Dog Spayed/Neutered:	Yes	No
5. Dog's Breed (If mixed choose dominant breed):	Select One Affenpinscher Afghan Hound Airedale Terrier Akita Alaskan Malamute American Eskimo Dog American Foxhound American Staffordshire Terrier American Water Spaniel Anatolian Shepherd Australian Cattle Dog Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Bearded Collie Bedlington Terrier Belgian Malinois Belgian Sheepdog Belgian Tervuren Bernese Mountain Dog Bichon Frise Black and Tan Coonhound Bloodhound Border Collie Border Terrier Borzoi Boston Terrier Bouvier des Flandres Boxer Briard Brittany Brussels Griffon Bull Terrier Bulldog Bullmastiff Cairn Terrier Canaan Dog Cardigan Welsh Corgi Cavalier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Chinese Shar-Pei Chow Chow Clumber Spaniel Cocker Spaniel Collie Curly-Coated Retriever Dachshund Dalmatian Dandie Dinmont Terrier Doberman Pinscher English Cocker Spaniel English Foxhound English Setter English Springer Spaniel English Toy Spaniel Field Spaniel Finnish Spitz Flat-Coated Retriever French Bulldog German Pinscher German Shepherd Dog German Shorthaired Pointer German Wirehaired Pointer Giant Schnauzer Golden Retriever Gordon Setter Great Dane Great Pyrenees Greater Swiss Mountain Dog Greyhound Harrier Havanese Ibizan Hound Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Japanese Chin Keeshond Kerry Blue Terrier Komondor Kuvasz Labrador Retriever Lakeland Terrier Lhasa Apso Lowchen Maltese Manchester Terrier Mastiff Miniature Bull Terrier Miniature Pinscher Miniature Schnauzer Newfoundland Norfolk Terrier Norwegian Elkhound Norwich Terrier Nova Scotia Duck Tolling Retriever Old English Sheepdog Otterhound Papillon Parson Russell Terrier Pekingese Pembroke Welsh Corgi Petit Basset Griffon Vendeen Pharaoh Hound Plott Pointer Polish Lowland Sheepdog Pomeranian Poodle Portuguese Water Dog Pug Puli Rhodesian Ridgeback Rottweiler Saluki Samoyed Schipperke Scottish Deerhound Scottish Terrier Sealyham Terrier Shetland Sheepdog Shiba Inu Shih Tzu Siberian Husky Silky Terrier Skye Terrier Smooth Fox Terrier Soft Coated Wheaten Terrier Spinone Italiano St. Bernard Staffordshire Bull Terrier Standard Schnauzer Sussex Spaniel Tibetan Spaniel Tibetan Terrier Toy Fox Terrier Vizsla Weimaraner Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Whippet Wire Fox Terrier Wirehaired Pointing Griffon Yorkshire Terrier Mixed Breed
6. Dog Acquired From:	Select One GHS Breeder Friend/Family Pet Store Gift Paper Found Other
7. Veterinarian:	Select One Bridge Veterinary Services Juneau Veterinary Hospital Southeast Alaska Animal Medical Center Walker Veterinary Service Other Douglas Island Veterinary Svc
8. Class or Service Requested	Select One FLEXIBLE-PuppyK/Basic Ob PuppyK-Foundations-6wk Basic Obed-Essentials-6wk Problem Solving Single Obed. Train class Treibball Freestyle/Tricks Loose Leash Walking Come! Settle! Street Smarts Fun Nose Work I Fun Nose Work II Open Play Time Extension Classes (4 wk) Good Dog, Forever! (Full course) Good Dog, Forever! Lecture only Private Consultation TTouch Grooming Doggone Fun Spa Dogs Other
9a. Add Bonus Bag of Equipment?	Yes	No	(Additional cost)
9b. Add 20' Longline only?	Yes	No	(Additional cost)
10. What training and/or behavior modification have you done so far with this dog? In what class or with what trainer and where?
For Puppy Kindergarten, Basic Obedience, Problem Solving and Private Consultations ONLY, please complete all the questions below. For all other classes, you may skip items 11-18 and 21, please complete 19-20 and 22-24.
11. List Family Members Your Dog Lives With or Sees Regularly (If children, list ages; also include other pets):
1.      2.      3.
4.      5.      6.
12. Your Training Experience:	Select One First Dog Trained Dog For Pet Trained Dog for Conformation Trained Dog for Obedience Ring Owned Previous Dog But Not Trained Other
13. Dog's Personality: (choose as many as apply)	Friendly to people Friendly to other dogs Overly shy around people Overly shy around other dogs Nervous around people Nervous around other dogs Aggressive towards people Aggressive towards other dogs Jumps on people Uses mouth to play Barks frequently Snaps or bites
14. Dog's Environment: (choose as many as apply)	Lives in house Not allowed in house Has fenced yard or run Allowed to run free Other dogs in family Only dog in household
15. What are your goals for you and your dog?
16. What do you like about your dog?
17. What is not so good about your dog?
18. How does your dog spend his/her day?
19. How did you learn of these classes:	Select One Newspaper Gastineau Humane Society Veterinarian Flyer Phone Book Television/Radio Brochure Web Friend Radio Other
20. What date will you be starting in the group class at 9447 LaPerouse?
21. (PuppyK/ Basic Obedience only) Prior to your first Friday class, what are several day/date/times that would work well for you to do your Quick Start individual lesson and orientation at our shop, 4191 Taku Blvd.? (We will contact you to schedule this lesson.)
22. List vaccinations/titers and current expiration dates: Rabies (required if 6 months or older), Bordatella (not required), and Distemper combo. You must have written documentation of the above vaccinations and are certifying that you can produce it at any time.
23. List special problems, considerations or needs for your dog, especially dog or people reactiveness or aggression:
24. Release:	I register the dog named above and release Canines Unlimited, Martha Fischbach, Shotokan Karate Club, other instructors and any other associated entity from all liability for damages or injuries of any nature that may arise in connection with training classes. I certify this dog has had puppy vaccinations and age appropriate vaccinations, and is immunized appropriately for health and safety, is in healthy condition, and is not a danger to other animals or humans. I certify I have and can produce written documentation of all vaccination information. Canines Unlimited has permission to use, and retains all rights to use any of my comments, any photos, or audio/video materials made for educational, informational, promotional or commercial purposes, such materials becoming the property of Canines Unlimited/Martha Fischbach.. I understand there are no credits, transfers or refunds. Training classes: Classes are to be completed within the course time frame for which registered. Classes may be added, combined, canceled or changed, subject to enrollment. Due to the flexible nature of class and enrollments, I understand the importance of being on time to assure my place in class, no reservations. Additional sections will be added if classes are regularly over attended. I have read, understood and agree with the class information, policies and fee structure, I agree to do my homework and agree to the payment schedule for which registered. I promise to immediately contact Canines Unlimited/Martha Fischbach with any questions, comments, or concerns I have about class. Yes, I agree (must check box)