APPLICATION FOR CANINE OBEDIENCE TRAINING CLASS
September 8 - October 26, 2009
Name ___________________________________________________________________ Age (if under 18) __________________
Address _________________________________________________ City/State/Zip _____________________________________
Place of Employment: __________________________ Occupation: _________________________ Work Phone: _______________
Home Phone: ____________________ Email Address: _____________________________________________
Breed of Dog _______________________________________ Date of Birth ____________________ Male or Female (Circle one)
Call Name of Dog ___________________________________ Veterinarian _____________________________________________
Number of family members living with dog ________ Ages of children living at home ____________________________________
Please list any other dogs or pets living with you __________________________________________________________________
Do you have any physical restrictions or health concerns that your instructor should know about? ___________________________
If so, what are they? _________________________________________________________________________________________
How long have you had this dog? _______________________________ Is this dog housetrained? ___________________________
Where does dog sleep? (Please be specific) Indoors? Outdoors? Garage?________
In dog bed? In crate or kennel? In bed with family member? Other?
How much and what kind of daily exercise does dog receive? _________________________________________________________
Is dog comfortable on a leash? Yes No Is dog fed: on a schedule or �free fed� (food always available)?
Is dog food-possessive? Yes No Is dog possessive of toys or objects? Yes No
Has this dog ever shown aggression toward you or other people? ______________________________________________________
Has this dog ever shown aggression toward other dogs? _____________________________________________________________
What was your primary purpose in acquiring this dog? _____________________________________________________________
What, if any, specific dog behavior problems would you like to solve? _________________________________________________
__________________________________________________________________________________________________________
Have you taken this dog through a class from Mason City Kennel Club before? If so, when? ___________________________
How did you learn about these classes? _________________________________________________________________________
Are you prepared health-wise and time-wise to spend some time every day working with your dog during training in order to achieve maximum benefits from this class? If not, please allow another student to fill this spot in class as we do not want to waste your time (or ours). If so, please read and sign the commitment clause below:
I, ________________________________________ (primary handler�s signature), commit to allocate time each day to work with training my dog. I vow to execute the training commands as illustrated by my instructor(s) and will put forth my best effort to implement each exercise, complete any worksheets, and review the articles, which will help me care for and train my dog.
AGREEMENT TO HOLD HARMLESS, WAIVER AND ASSUMPTION OF RISK
I understand that attendance of a dog training class is not without risk to myself, members of my family, or guests who may attend, or my dog, because some of the dogs to which I will be exposed to may be difficult to control and may be the cause of injury even when handled with the greatest amount of care.
I hereby waive and release the �Mason City Kennel Club� hereinafter referred to as the �Training Organization�, its employees, officers, members, and agents from any and all liability of any nature for injury or damage which I or my dog may suffer, including specifically, but without limitation, any injury or damage resulting from the action of any dog and I expressly assume the risk of such damage or injury while attending any training session, or any other function, of the Training Organization, or while on the training grounds or the surrounding area thereto.
In consideration of and as inducement to the acceptance of my application for training membership by this Training Organization, I hereby agree to indemnify and hold harmless this Training Organization, its employees, officers, members, and agents from any and all claims, or claims by any member of any family or any other person accompanying me to any training session or function to the Training Organization or while on the grounds or the surrounding area thereto as a result of any action by any dog, including my own.
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Signature of Owner or Authorized Agent (In case of a minor, a parent or legal guardian must sign.)
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Signature _____________________________________________________________ Date ______________________
attn: Training Comm.
P.O. Box 1336
Mason City, IA 50402-1336
reserves the right to refuse
admittance of any dog into classes
or on the training premises. ***
Class Fee: _______________ Ck# _______________ (or Cash) Total Paid: $________
Date Vaccination Expires: __________ Rabies __________ DHPP __________ Vaccinations checked by: __________
Class/Time: __________ Instructor(s): ______________________________ Public _____ Club Member _____