Park Cities Obedience School

Registration Form

Your Information:

First Name *

Last Name *

Driver's License #: *

Street Address *

City *

State *

Zip Code *

Email Address *

Hm. Ph:

Wk. Ph:

Cell: *

Emergency Contact Information

Name: *

Phone: *

Relationship: *

Vet's Name: *

Vet's Number: *

Your Dog's Information:

Dog's Name: *

Breed/Mix: *

Date of Birth: *

Male/Female?: *

Spayed/Neutered?: *

Vet Clinic: *

Distemper/Parvo Combo: *

Rabies: *

Bordetella: *

***We only require that you put the dates that the shots expire***

Reason for Visit: *

Board/Train

Daycare

Boarding

Latchkey

Dog Profile:

How did you hear about us? *

Any kids in the household? *

Please tell us where you got your dog (what breeder, shelter, rescue group etc.) *

What brand of food does your dog eat? *

Does your dog take medications? *

If so, for what? *

How often? *

Does your dog have any past injuries or any current conditions? *

Is your dog frightened by any noises? *

Is your dog frightened around anything else? *

What happens when you or somebody else tries to take food or toys from your dog? *

Does your dog get along well with other dogs? *

What commands does your dog know(if any)? *

Does your dog have any sensitive areas on the body? *

How does your dog react to strangers? *

Are there any types of people that your dog automatically dislikes or fears? *

Rate your dog's energy level "1" being very mellow and "10" being a total spaz: *

Does your dog show any destructive behaviors when you aren't at home? *

Does your dog jump up on you? *

On others? *

Is your dog aggressive on leash? *

Off leash? *

Does your dog growl? If yes, what is the cause? *

Do you walk your dog? And if yes, how often? *

Has your dog ever bitten anybody? *

Is yes, please explain why it happened? *

Has your dog ever jumped or climbed over a fence? *

If yes, how high was it? *

If here for training, what problems are you having with your dog and what do you hope training will accomplish? *

Liability Waiver/Health & Temperament Agreement

I understand and agree that in admitting my dog, Park Cities Obedience School (hereby known as PCOS) has relied on my representation that my dog is in good health and has not harmed or shown aggression or threatening behavior towards any person or any other dog.

Initial Here *

2. I understand that when dogs are exposed to each other they are at an increased risk of catching communicable diseases and picking up parasites that are common to canines. You dog may become ill even though he/she has been vaccinated. Common illnesses/parasites include (but are not limited to) upper respiratory infections, giardia, internal parasites.

Initial Here *

3. I understand and agree that PCOS and their staff will not be liable for any problems that develop provided reasonable care and precautions are followed, and I hereby release them of any liability of any kind whatsoever arising from my dog’s attendance and participation in activities at PCOS

Initial Here *

4. I understand and agree that any problem that develops with my dog will be treated as deemed best by the staff of PCOS, in their sole discretion, and that I assume full financial responsibility for any and all expenses involved in treatment.

Initial Here *

5. PCOS reserves the right to refuse admittance to any dog that does not meet the health and temperament requirements.

Initial Here *

6. I understand that dogs at PCOS must spend time outside to relieve themselves. This may result in the dogs becoming dirty, stained, wet and/or muddy depending on the weather.

Initial Here *

7. I understand that dogs can and will play roughly with each other and will use their teeth and nails during play. This can result in the dogs’ receiving nicks, cuts, scratches and/or bites.

Initial Here *

8. I understand that items such as toys, beds, blankets, etc. brought in with dogs may be destroyed by the dogs during play or inadvertently lost

Initial Here *

9. I certify that I have read and understand the rules and regulations of PCOS as set forth in this agreement. I agree to abide by the rules and regulations and accept all the terms, conditions and statements of this agreement.

Initial Here *

10. All owners and/ or guardians of dogs that enter the Park Cities Obedience School facility assume financial responsibility for any and all expenses incurred,veterinary related or otherwise, in the event that their dog causes harm to another dog at Park Cities Obedience facility.

Initial Here *

Signature of Owner/Agent *

clear

Veterinary Treatment Consent

To whom it may concern: During my absence Park Cities Obedience School (PCOS) will be caring for my pet(s). I give PCOS my permission to transport my pets to my veterinarian (or to an emergency clinic). In the event I cannot be reached, I authorize PCOS to act as an agent on my behalf regarding my pets’ medical care. I authorize veterinary treatment and accept full responsibility for charges incurred in the treatment of my pet(s), not to exceed the following amounts for each pet:

Pet Name(s) & Description: *

Maximum Amount if any:

(or write N/A if you DO NOT wish to set a maximum you will spend on your dogs care).

$ *

$

I understand that PCOS assumes no responsibility for the loss of any pet and is released from all liability related to transportation, treatment and expense.

Initial Here *

I do / do not agree to authorize said veterinarian to euthanize my pet in extreme circumstances under his/her advisement after all reasonable attempts have been made to reach me.

*

Do

Do Not

Initial Here *

This consent for treatment has no expiration date unless otherwise noted. A photocopy/facsimile of the signed consent shall have the same force and effect as the Client/Pet Owner’s original signature.

Initial Here *

This form will be retained on file and will be used to authorize veterinary treatment in the event that your pet(s) require treatment during your absence, while in our care, and we are unable to contact you at the time.

* This form MUST be signed to authorize treatment.

Client Signature Name *

clear

Credit Card Authorization

Dog's Name:

Owner's Name:

Co-Owner's Name:

Owner agrees that this credit card can be used for any and all services performed by Park Cities Obedience School for the dog(s) named above.

By signing this agreement, the Owner agrees that this credit card can be used to pay for dog daycare, boarding, grooming, bathing, training, reimbursement for veterinary bills incurred on behalf of the above mentioned dog(s), including veterinary emergency room bills, bills at the Owner’s veterinarian and bills at the veterinarian used by Park Cities Obedience School, deposits for boarding reservations and no-show and cancellation fees. Owner also agrees that this credit card can be used for bank fees in the event that a check is returned for any reason.

Credit Card Type:

Credit card number:

Expiration date:

Billing zip:

Signature

clear