ONLINE APPLICATION FOR TRAINING
Please note that your spot in a class is not reserved until payment is received.
Class Information:
Class Start Date:
Class Time:
Handler Information:
Your Full Name:
Street Address: City/State/Zip: Home Phone Number: Cell Phone Number: Alt. Phone Number: Email Address: Alt. Email Address: How do you plan to pay for this class? I understand my spot is not secured until I have paid for the class. Pay Online (preferred) Pay By Check (mail in) Pay With Certificate (mail in) Handler Age (Only Needed if Under 18, or if over 65 and requesting senior ($5) discount): Have you trained a dog before? Yes No If yes, where and when?: How did you hear about SMDTC? (Check all that apply.) Student - Student Name Member - Member Name Veterinarian - Vet Name Groomer - Groomer Name Kennel - Kennel Name Newspaper Drive By-Sign Internet Other Please List Dog Information: Breed:
City/State/Zip:
Home Phone Number:
Cell Phone Number:
Alt. Phone Number:
Email Address:
Alt. Email Address:
How do you plan to pay for this class? I understand my spot is not secured until I have paid for the class. Pay Online (preferred) Pay By Check (mail in) Pay With Certificate (mail in)
Handler Age (Only Needed if Under 18, or if over 65 and requesting senior ($5) discount):
Have you trained a dog before? Yes No
If yes, where and when?:
How did you hear about SMDTC? (Check all that apply.) Student - Student Name
Member - Member Name
Veterinarian - Vet Name
Groomer - Groomer Name
Kennel - Kennel Name
Newspaper
Drive By-Sign
Internet
Other Please List
Dog Information:
Name of Dog:
Date of Birth:
Sex Male Female
Spayed/Neutered? Yes No
Vaccinations: List date last received. You must bring vaccination records to the first class if not previously mailed/e-mailed. Rabies:
Has your dog ever growled or snapped at anyone? Yes No If yes, briefly state circumstances: Has your dog ever bitten any person? Yes No If yes, briefly state circumstances: Does your dog show aggression or fight other dogs? Yes No If yes, briefly state circumstances:
Briefly state what you hope to accomplish in training this dog:
Agreement to Hold Harmless Waiver and Assumption of Risk
I understand that attendance at a dog obedience or other training class is not without risk to myself, members of my family, guests who may attend, or my dog, because some of the dogs to which I will be exposed may be difficult to control and may be the cause of injury even when handled with the greatest amount of care. I hereby waive and release the Springfield, Missouri Dog Training Club, Inc. hereafter referred to as SMDTC, its employees, members, and agents from all liability of any injury or damage resulting from the action of any dog, and I expressly assume the risk of such damage or injury while attending any training session, or any other function of SMDTC, or while on the training grounds or surrounding area thereto. In consideration of and as inducement to the acceptance of my application for training by SMDTC, I hereby agree to indemnify and hold harmless SMDTC, its employees, officers, members, and agents from any and all claims by any member of any family or any other person accompanying me to any training session or function of SMDTC, or while on the grounds or the surrounding area thereto as a result of any action by any dog, including my own. By selecting "I agree" below I am agreeing with the statements above, and understand this selection serves as my official signature. Further, I certify that I am the person with the legal authority to accept this assumption of risk and hold harmless waiver.
Owner or Authorized Agent - Enter Name: I Agree - checking this box serves as my official signature and certifies that I am the person with the legal authority to accept this assumption of risk and hold harmless waiver. I Do Not Agree Parent or Legal Guardian if Handler is a Minor - Enter Name: I Agree - checking this box serves as my official signature and certifies that I am the person with the legal authority to accept this assumption of risk and hold harmless waiver. I Do Not Agree Handler (if different from Owner) - Enter Name: I Agree - checking this box serves as my official signature and certifies that I am the person with the legal authority to accept this assumption of risk and hold harmless waiver. I Do Not Agree Your registration will not be accepted if you do not wish to agree to these terms.