Registration

Dog’s Information:

Name :

Breed :

Sex :

Age :

Birthday :

Spayed or neutered:

NoYes

At what age was this done?

Weight (approximate) :

Colour/markings :

Microchip or Tattoo :

If adopted, do you have any knowledge of your dog’s past history that is relevant to their care?

How long have you had your dog? :

Does your dog have anyphysical or medical problems past or present that we should be made aware of

YesNo

If yes, please elaborate:

Guardian Information:

First name :

Last name :

Street Address :

Apt :

City :

Postal code :

Home Phone :

Cell Phone :

Gardian Work Phone :

Email address :

*If anyone other than the guardian(s) has permission to pick up your dog, please give us their names :

How did you hear about Doggieville?

Emergency Contact:

First name :

Last name :

Home Phone :

Cell Phone :

Veterinary Information:

Name of Veterinarian :

Name of Clinic :

Address :

Phone :

Fax :

Vaccination Dates :

Rabies (1 or 3 years) :

DHPP (Distemper, Hepatitis, Parvovirus, Parainfluenza) :

Bordetella (kennel cough) :

Titers date (if applicable):

Fecal exam date :

Results :

Treated for parasites :

Medication :

Is your dog on any flea/heartworm prevention program?

YesNo

If yes, please explain :

Temperament & Behaviour:

Has your dog ever been in daycare?

YesNo

If yes, where?

Was it a good experience for your dog? Please explain :

What are your reasons for enrolling in daycare?

Socialization & Play Exercise Long day

Other:

Are you planning on attending daycare:

regularlyoccasionally?

If yes, please explain:

Does your pet have separation anxiety issues?

YesNo

If yes, please elaborate:

Has your dog had any formal obedience training?

YesNo

If yes, where did you attend?

What type? (please circle which apply )

Puppy/Beginner Intermediate Advanced Canine Good Citizen

TricksFlyballScent DetectionRally

Is your dog housetrained?

YesNo

Does your dog mark (his/her) territory with urine?

YesNo

Has your dog ever growled at anyone?

YesNo

If yes, please elaborate :

Has your dog ever bitten a person or animal?

YesNo

If yes, please elaborate :

Does your dog guard his/her food?

YesNo

Toys

YesNo

If yes, please elaborate :

Describe what happens when you take your dog’s food or toys away from him/her :

Does your dog get along well with other dogs?

YesNo

Puppies

YesNo

Does your dog get along or play with large dogs?

YesNo

Small dogs

YesNo

Is your dog ever aggressive with other dogs he/she is playing with?

YesNo

If yes, what are the circumstances that cause the aggression?

What are your dog’s fears or dislikes? (Please list any visual or audible)

Is your dog comfortable with having his/her feet touched?

YesNo

Is your dog comfortable with having his/her collar used to lead?

YesNo

Does your dog chew inappropriate items?

YesNo

Does your dog like:

Children

YesNo

Men

YesNo

Women

YesNo

Strangers

YesNo

Belly rubs Brushing Massage

Other:

What is his/her favorite place to go potty (i.e. outside, on newspaper, potty pad, etc.)?

Does your dog have a bathroom command?

YesNo

If so, what is it?

Rate your dog’s energy level “1” being very mellow and “10” being high:

Is your dog (please check all that apply):

Allowed to run free in the home:

supervised unsupervised

Allowed to run in a fenced yard:

supervised unsupervised

Leash walked only Outside unleashed but supervised

How much exercise is your dog presently getting?

Does your dog have any exercise limitations?

Yes No

What are your dog’s fears or dislikes? (Please list any visual or audible)

What else can you tell us about your dog?

Feeding

My dog eats:

YesNoNo

cup(s) at each meal :

Special Feeding Instructions:

Yes No

If so, please elaborate:

What type of food do you feed your dog?

Is your dog allowed treats?

YesNo

You are responsible for informing us of any and all incidents of bites or aggression concerning your dog (dog to dog, dog to human, etc.). Failure to do so may result in your day care service agreement being terminated.

Veterinary Release

In the event that my dog requires emergency veterinary care during his/ her stay at Doggieville, I grant permission to Doggieville Inc. to act on my behalf and ensure my dog receives all the veterinary services required. I also agree to pay for all associated fees that may result from these services.

I agree to release Doggieville Inc., its officers, directors, employees and volunteers from any liability as a result of any injury or illness my dog may incur while in the care of the professionals at Doggieville Inc. I further assume any and all expense and liability for injuries that my dog may inflict upon any human or dog while in the care of Doggieville Inc.

To the best of my knowledge, I have made Doggieville Inc. aware of any and all health and behavioural issues regarding my dog. I grant Doggieville Inc. full access to my dog’s veterinary records.

Health and Temperament Statement

I understand that I am solely responsible for any harm or damage caused by my dog(s)while in the care of Doggieville Inc. Iunderstand and agree that, in entering into this Agreement, Doggieville hasrelied on my representation that my dog(s) is/are in good health and free fromany infectious diseases or parasites within the last thirty days.

Ihereby represent and warrant that my dog(s) have not harmed or shown anyaggressive or threatening behaviour towards any person or animal. I understandand agree that Doggieville Inc. shall not be held liable for any actions by mydog(s) and hereby release Doggieville Inc. from any liability.

Iunderstand that problems arising with my dog(s) shall be treated as deemed bestunder the sole discretion of Doggieville Inc. and I assume full financialresponsibility for any and all expenses involved. I assume the risk of any damage or injurywhich my dog(s) may suffer, including but not limited to any injury or damageresulting from the action of my dog(s).

Icertify that I have read and understand this Statement, and that it is true tothe best of my knowledge and belief.

MediaRelease

Ihereby give permission for images of my dog(s), captured during regular andspecial activities through video, photo and digital camera, to be used solelyfor the purposes of Doggieville promotional material and publications on ourwebsite and social media accounts.

MediaRelease

I.

Daycare Registration Form