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Maplewood Dog Training

Katrin Andberg Hawkins, CBCC-KA, CDBC

781 806 5707

www.maplewooddog.com

Generic Registration Form

for Remote Private Lessons & Agility Private Lessons

Please email your completed form to at least 48hrs before your scheduled lesson. Thank you and I look forward to consulting with you and your dog!

Owner Contact Information:

Name:______

Address:______

Town:______State:______ZIP:______Time Zone: ______

Day Time Phone:______Circle Type: Cell, Work, Home

Evening Phone:______Circle Type: Cell, Work, Home

E-mail address:______

For remote private lesson please indicate your preferred means to connect & write the best phone # or user email on the line provided:

Skype ______

Telephone ______

Dog Info: (if more than 1 dog to be included in lessons, please give info for all dogs)

Dog Name:______Dog Breed/Mix:______

Dog DOB:______Age of dog at time of consult:______
Date of last Rabies Vaccination:______Name of Vet Hospital:______

Does your dog have any known medical concerns I should be aware of? Yes No

If yes, please list them including time of onset, veterinary recommendations and any current medications your dog is given for the concern.

·  Do you take weekly dog training classes at this time with your dog? Yes No

·  If yes, for how long have you been in weekly classes with your dog? ______

·  Do you train your dog at home? Yes No

·  If yes, how often and for how long each session do you train your dog at home? ______

·  Have you previously consulted with a professional regarding the problem or concern you are seeking feedback for today? Yes No

·  If yes, what recommendations have already been made and on a scale of 1 - 10 (1 being needs/goals not met at all, 10 being needs/goals met in the best way possible) how well did you feel those recommendations helped you meet your goals and needs at that time?

Lesson Information:

Briefly describe the primary reason for scheduling this consult. Use bullet points whenever possible.

Goals:

·  What are your long term goals (1+ year) with your dog regarding what we are consulting on today?

·  What are your short term goals (less than 1 year) with your dog regarding what we are consulting on today?

·  What is your goal for this month with your dog?

·  How do you feel I might best be able to help you meet those goals?

·  If you have any videos that you would like me to review before our scheduled lesson time, please include the youtube links here & briefly give a description why you chose to include this particular video clip if applicable.

WAIVER: You MUST fill out and sign attached waiver to participate in on site lessons. If you violate said waiver, you will be dismissed from the session with no refund

Maplewood Dog Training & Katrin Andberg Hawkins

353 N Main St, Sharon, MA 02067

Assumption of Risk and Agreement to Hold Harmless

I understand that attendance at a dog training class, private lesson or event is not without risk to myself, members of my family or guests who may attend, or to my dog, because accidents may occur on. The undersigned does hereby remise, release and forever discharge Maplewood Dog Training and its officers, directors, owners, employees, agents or representatives (all hereinafter called the indemnities), of and from, or for any and all actions, claims, demands and liabilities, for, upon, or by reason of any damage, loss, or injury to the undersigned, or any other person, or any dog, or property resulting from, or related to, any accident or injury (including dog bite) which may occur during, or in the vicinity of, any dog event, lesson or clinic, or demonstration, in connection with the aforesaid Maplewood Dog Training. The undersigned further expressly agrees to indemnify and forever hold harmless the indemnities from any and all actions, causes or action, claims, demands, liabilities, costs and expenses which may be asserted to persons, dogs, horses, livestock, or property caused by and dog owned by, or in the custody of, the undersigned.

I have read and understand the Refund Policy. Copies of these documents may be found at www.maplewooddog.com

Print Name:______

Signed:______Date ___/___/___

Parent or Guardian______
(if applicant is a minor)