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Pet Portal|Animal Clinic (765) 463-2611 | Kennels (765) 463-1603

Canine Companion Clicker Course

Dog's Name:

Your Name:

Email Address:

Address:

Daytime Phone Number:

Nighttime Phone Number:

Dog Breed Information:

Breed:

Age:

Sex:

Male

Female

Male/Neutered

Female/Spayed

Please provide your Veterinarian's information:

May we contact your veterinarian to acquire proof of vaccination for your pet?

yes

no

Goals:

What would you like to accomplish by bringing your dog to the Canine Companion Class?

1.
2.
3.

How did you hear about Klondike Canine Academy? (Check all that apply)

I'm a current client

My Veterinarian

Someone referred me

Pet Store

Groomer

Facebook

Telephone Book

Breeder

Webpage

Newspaper

Other

If someone referred you, who may we thank?

Where was your dog acquired from?

Age of dog when acquired:

How long have you had your dog?

Has your dog ever attended a training class?

Yes

No

If yes, where:

What do you like most about your dog?

What concerns you most about your dog's behavior?

Please check all behaviors that you are concerned with:

Barking

Jumps up on people

Eliminates indoors

Pulls on leash

Aggressive to humans

Aggressive to cats

Shy/Nervous/Fearful

Destructive Chewing

Does not listen to me

Growls if I try to take a chew/toy away

Aggressive to dogs

Other

Has your dog every shown any behaviors such as baring teeth, growling, or snapping toward:

	yes	no
Adults
Children
Another Pet/Animal

If you answered yes, to any of these, please explain:

Indemnification and Hold Harmless Agreement

I, the undersigned, in consideration of my participation in the Klondike Canine Academy training classes which will be conducted at Klondike Kennels and/or Klondike Canine Recreation and Sporks Park, do hereby agree to indemnify and hold harmless Blair Animal Clinic, PC, and Klondike Kennels, Inc., their officers, agents and employees, volunteers and students, from and against any losses, costs, damages, and expenses, including attorney's fees, arising out of or resulting from claims or suits, by or on behalf of any person, for any injury to me, a member of my family and any guest invited by me who is permitted to attend such training classes, and./or any injury to my dog, of whatever cause or nature, arising out of my participation in said training classes and related activities where or not such injuries are caused in whole or in part by the negligence or other fault of Blair Animal Clinic, PC and Klondike Kennels, Inc., their officers, agents and employees, volunteers and students.
I, the undersigned, represent that I am at least eighteen (18) years of age, understand the obligations I am undertaking by this Agreement, and am executing this Agreement freely and voluntarily.

Refund Policy

Full payment is required at the time of registration If you are unable to complete a class due to the enrolled pet suffering an unexpected illness or injury, a credit may be issued at our discretion for any funds not used. Any credit issued will be applied to use for future behavior or training services we offer. All credits are calculated subtracting the cost of supplies and the per session fee for each session attended. We regret that no credits or refunds can be provided for any other reason .

Photo/Video/Email Release

By signing below I agree to allow KCA to use class video and photos for educational or training purposes, (for example, slides, videos, and/or website) and to be contacted via email to announce KCA activities unless stated otherwise. Emails are not sold and are used specifically to announce KCA classes and training events only.

Please check "yes" below to confirm that you agree with all of the above.*

Yes

No