For Internal Use Only: Paid Waiver Vaccination Proof Bunker Hill Dog Training Registration Agreement Handler/Owner’s Data



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For Internal Use Only: _____Paid _____Waiver _____Vaccination Proof
Bunker Hill Dog Training Registration Agreement
Handler/Owner’s Data
Name ___________________________________________________ 18 Years or older? _____Yes _____No
Address __________________________________________________________________________________________
City/State/Zip_____________________________________________________________________________________
Telephone: Work_______________________ Home_______________________ Cell_______________________
E-mail Address:____________________________________________________________________________________
Where did you hear about these classes? _____Newspaper _____Flyer _____Referral _____Other
Name of Newspaper or Referral:_____________________________________________________________________
Dog’s Data
Dog’s Name ___________________________________ Breed ______________________________________________
Circle: Male Female Spayed/Neutered _____Yes _____No Dog’s Age ________________________
Veterinarian’s name and number _______________________________________________________________________________
What problems are you having with your dog?___________________________________________________________________
Who is responsible for care and feeding in your household?________________________________________________________
Dog lives: _____Indoors _____Outdoors _____Out day/In night
Dog has a problem with: _____Children _____Other Dogs _____Adults _____Cats
_____Other (Describe)_______________________________________________________________________________________
Where was dog obtained? _____Breeder _____Shelter _____Stray _____Pet Store _____Newspaper Ad
_____Other (Describe)________________________________________________________________________________________

Class:_____________________________ Day & Time:___________________________ Start Date:________________________

Please return this completed, signed registration agreement along with a copy of

vaccination/worming records and the appropriate registration fee(s) to:

Bunker Hill Dog Training, 6982 S. Bunker Hill Road, German Valley, IL 61039 E-MAIL: regole06@yahoo.com

PLEASE COMPLETE AND SIGN REVERSE SIDE OF THIS FORM

How long have you owned your dog?___________________________________________________________________________
How many adults are in your household?________ Children?_______ Ages of Children?______________________________
Do either you or your dog have any medical condition or handicap that we should be aware of? (If so, what is the condition?)
____________________________________________________________________________________________________________

PERSON TO CONTACT IN THE EVENT OF AN EMERGENCY (Not yourself)

Name:____________________________________________________ Phone Number:__________________________________

AGREEMENT:
I (we) fully understand that I am responsible for the control of my dog at all times while on the premises of Bunker Hill Dog Training. I agree to hold this business, its owners, directors or agents harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or upon the premises or grounds or near any entrance thereof and I (we) personally assume all responsibility and liability for any such claim and I (we) further agree to hold the aforementioned parties harmless from any claim for loss of this dog by disappearance, theft, death or otherwise, and from any claim for damage or injury to the dog, whether such loss, disappearance, theft, damage or injury be caused or alleged to be caused by the negligence of any of the parties aforementioned, or by the negligence of any other person, or any other cause or causes. I (we) hereby assume the sole responsibility for and agree to indemnify and save the aforementioned parties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting therefrom, sustained by any person or persons, including myself (ourselves), or on account of damage to property, arising out of or in consequence of my (our) participation in this class howsoever such injuries, death or damage to property may be caused, and whether or not the same may have been caused or may allege to have been caused by negligence of the aforementioned parties or any of their employees or agents, or any other person. I agree to abide by the Rules and Requirements and I have received a copy of same prior to signing this agreement. I understand that the registration fees are non-refundable.
ANY PARTIES UNDER 18 YEARS OF AGE MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN WHO MUST ALSO ATTEST AND AGREE TO THE AFOREMENTIONED STATEMENTS.

THE PARENT OR GUARDIAN WILL BE HELD RESPONSIBLE AND LIABLE FOR

THE MINOR’S CONDUCT AND SAFETY WHILE ON THESE PREMISES.

_____________________________________________________________ ________________________

Owner(s) Date

_____________________________________________________________ ________________________



Handler Date


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