City: _______________________________ State___________ Zip ____________
Home Phone: __________________Work___________________Cell__________________ E-Mail: ___________________________________________________________________
Do you have any physical handicaps or hearing difficulties___________________________
If yes, please explain: ________________________________________________________
Dog’s Name: ___________________________ Date of Birth: ________________________
Age Obtained: _______________ From Where: ____________________________________
Have you owned a dog before: _______ If yes, what breed: ___________________________
Have you trained a dog before: _______ Where: ___________________ When: ___________
Does your dog have any physical problems or disabilities which may affect
his or her training: ______ If yes, please explain: _____________________________________
Name of Veterinarian: _________________________________________________
Vaccine History: Due date of RABIES: __________________DHLP-P: __________________
What brought you to this class: ___________________________________________________ How did you hear about us: ______________________________________________________
