Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Mobile Phone
E-mail
Dog's Name
Breed
Age
Sex	Male Female Neutered Male Spayed Female
Which Class ?	Which Class is Right for you? Puppy Kindergarten Dog School Small Dogs Class Advanced Class Canine Good Citizenship Agility for Fun Oh Come On! Tricks Senior DENizens Taking It On the Road! Not at this time, thanks.
Class Location?	Select a Class Location Aliso Viejo Irvine Laguna Beach San Clemente Not Applicable
Class Start Date?	Pick a start date-- Check the Schedule to be sure that you choose the date that goes with the location you chose, above! 3/3 3/4 3/6 3/10 3/11 3/13 3/15 4/24 5/8
Where did you get your dog?	Breeder Shelter Rescue Organization Pet Store Private Party Found Other
How old was your dog when acquired?
What are your goals  with your dog:
in class?
beyond class?
Behavior Issues
Has your dog ever growled or snapped at:
A person?	No Yes
Another dog?	No Yes
If yes to either of the above, please explain:
Has your dog ever bitten:
A person?	No Yes
Another dog?	No Yes
If yes to either of the above, please explain:
Does your dog have problems staying alone?	No Yes
If yes, please explain::
Does your dog have other behavior issues?
Are you interested in scheduling/finding out about a Behavior Consultation?	Not at this time. Yes
Are you interested in finding out about DubDubDog's other services: Private Lessons, Advanced Class, Boarding&Training?	Not at this time. Yes
If yes, please specify which service you would like to find out about:
Who is your dog's groomer, if any?
Who is your dog's veterinarian?
Whom may we thank for referring you to DubDubDog?
Contact information for Referrer, if appropriate
Release from Liability and Indemnification (Read before signing) Acting on behalf for myself, my child or ward, I agree to waive and release DubDubDog of Laguna Beach, its officers, agents, and employees (hereafter “DubDubDog”) from and against any and all claims, liability, or judgments arising out of my (or my child or ward’s) participation in this activity, whether resulting from DubDubDog’s negligence or otherwise. I agree to indemnify, defend, and hold harmless DubDubDog from and against all such claims, whether caused by negligence or otherwise. I understand that there is an inherent risk of death, personal injury, or property damage in recreational activities, and I expressly assume all risks arising from my (or my child or ward’s) participation in the activity, whether arising from DubDubDog’s negligence or otherwise. I understand that the effect of this document is to release DubDubDog from all liability arising from my (or my child or ward’s) participation in this activity to the fullest extent permitted by law. I have read and understand the above Release from Liability and Indemnification as indicated by my signature to the right:
I hereby grant DubDubDog permission to use my likeness in a photograph in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property DubDubDog and will not be returned.
Comments:

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