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E-Mail:
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Owner/Handler Name:
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Billing Address:
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City:
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State:
Zip:
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Work:
Cell:
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| 1. Dog's Name: |
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2. Dog's Gender:
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Male |
Female |
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3. Dog's Age:
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Years |
Months |
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4. Dog Spayed/Neutered:
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Yes |
No |
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5. Dog's Breed (If mixed choose dominant breed):
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6. Dog Acquired From:
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7. Veterinarian:
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| 8. Class or Service Requested |
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| 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? |
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| 11. List Family Members Your Dog Lives With or Sees
Regularly (If children, list ages; also include other pets): |
1.
2.
3.
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4.
5.
6.
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| 12. Your Training Experience: |
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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
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| 15. What are your goals for you and your dog? |
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| 16. What do you like about your dog? |
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| 17. What is not so good about your dog? |
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| 18. How does your dog spend his/her day? |
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19. How did you learn of these classes:
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| 20. What Friday date will you be starting in the group
class at 9447 LaPerouse? |
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| 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.) |
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| 22. List vaccinations/titers and current expiration
dates: Rabies (required if 6 months or older), Bordatella, and Distemper
combo. You must have written documentation of the above vaccinations. |
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| 23. List special problems or needs: |
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| 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, 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 written documentation
of all vaccination information submitted.
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 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)
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