Lucky Bones Country Club LLC
Canine Profile
1. Owner’s Name ______
2. Guest’s Name ______
3. Preferred Name ______
4. Breed Type ______
5. Color? ______6. Birthday ______
7. Approximate Weight ______
8. Male/Female ______
9. Spayed/Neutered ______
10. How long have you owned your Pet? ______
11. Where/how did you get your pet? (adoption, Breeder, stray) ______
12. Does your pet have fleas? Yes/No
13. Is your pet on heartworm preventatives? Yes/No
14. Does your pet have hip dysplasia? Yes/No
15. Does your pet mind if he/she is brushed? Yes/No
16. Is your pet sensitive in any areas? Yes/No
If so, where? ______
17. How does your pet interact with other K-9’s? Good/Not Good
18. Does your pet interact with strangers well? Yes/No
19. Is your pet afraid of any noises or items? Yes/No
If so, what?
20. Does your pet have a barking or growling problem? Yes/No
21. Does your pet growl or snap when his/her toy or food is taken away?Yes/No
22. Is there anyone that your pet doesn’t like? ______
23. What is your pet’s favorite toy? ______
24. Does your pet share his/her toys? Yes/No
25. Has your pet ever tried to jump a fence? Yes/no
26. Is your pet housetrained? Yes/no
27. Are you interested in enrolling your pet in obedience classes? Yes/No
28. Has your pet ever had any professional training? Yes/no
29. On a scale of 1-10, 1 being low and 10 being high, what is your pet’s
Energy level? 1 2 3 4 5 6 7 8 9 10
30. Does your pet know any commands? Yes/no
31. Does your pet like water? Yes/no
32. Will playing in the pools be a problem for you or your pet? Yes/no
33. Has your pet ever been lodged before? Yes/no did they do well? Yes/no
34. is there any health concerns with your pet? Yes/no
If so, what? ______
35. Is there any restrictions to your pet’s activities or movements? Yes/No
36. Is your pet allergic to anything? Yes/No If so what? ______
37. Does your pet tend to chew up anything? Yes/No
38. Does your dog tend to dig? Yes/No
LBCC Club Member Guidelines
Please sign at the bottom of the page stating that you have read and agreed to the following statements.
1. My pet is up to date on all of his/her shots.
Dogs: Rabies, DHPP, Bordatella, and Fecal test
Cats: Rabies, FVRCP (Feline Distemper), and Feline Leukemia
2. My dog or cat is on a flea and tick preventative.
3. My dog will be on a leash when being dropped off and picked up with a quick release or snap collar.
4. If my pet prefers to bring his own food, I will have the food in a container or bag with my name on it.
5. If you prefer LBCC to provide food there will be an additional fee of two dollars per night.
6. I will label my name on everything I bring in for my pet.
7. If my pet has any medications, I will bring them in the original container with the strength, vet’s name, and amount to be given indicated.
8. If my pet would like to bring anything that makes him/her more comfortable, I will label everything with my name indicated.
9. I will reserve my pet’s room 24 hours before arrival.
10. I will give a 24 hours notice if I need to cancel my reservation, 7 days notice for Holiday Reservations.
11. I will give an estimated drop off and pick up time when making my reservations.
Signature: ______Date:____/____/______
Lucky Bones Country Club
Emergency Contact Information
Owner Information:
Name:______
Address:______
______
______
Email: ______
Phone Numbers: Home:______
Work: ______
Cell: ______
Emergency Contact: Must be someone living locally.
Name:______
Phone Numbers: Home______
Work______
Cell______
How did you hear about us? ______Newspaper Ad ____Friend _____Drive By
____Vet Referral ____Chamber of Commerce____ Other:______
Pet Information:
Name______
Breed______
Sex______Birthdate______Weight______
Veterinarian:
Name______
Address______
Phone Number______
Lucky Bones Country Club, LLC
Statement of Authorization
I/We______ by signing this
“Statement of Authorization”, are authorizing my/our Veterinarian to provide any
information necessary for proper care of:
______
In my/our absence. I/we hereby give my/our permission to treat above pet for any injuries
or sickness which they might display.
Signed:______
Name: (please print)______
Date:______
Lucky Bones Country Club, LLC
Authorization for Pick-Up
I/We ______by signing this “Authorization for Pick-Up”, are authorizing the following person/people
______
to pick-up in my/our absence. Said person will provide proof of identification when picking up my/our pet.
Signed: ______
Name: ______
Date: ______
Owner/Guardian Agreement
This is an Agreement between Lucky Bones Country Club, LLC and the pet owner whose signature appears below.
1. I acknowledge that I am the sole Owner/Guardian of ______,
free and clear of all liens or encumbrances.
______2. I agree to pay the cost for boarding, grooming, daycare and any other services
in effect prior to the above pet being checked into Lucky Bones Country Club, LLC and to pay for any and all additional services requested or deemed necessary when the above pet is picked up by the owner/Guardian. Owner/Guardian further agrees that the above pet shall not leave Lucky Bones Country Club, LLC until all charges incurred are paid to Lucky Bones Country Club, LLC by Owner/Guardian. In any case of nonpayment, whether by negligence or abandonment, Owner/Guardian will remain liable to Lucky Bones Country Club, LLC for all unpaid charges including court costs and reasonable attorney fees incurred in the collection of the charges.
______3. I further understand and agree that by admitting the above pet to Lucky Bones
Country Club, LLC, Lucky Bones Country Club, LLC’s staff has relied on the Owner/Guardian’s representation that the above pet is in good health and has not harmed or shown aggressive or threatening behavior towards any person or any other dog.
______4. I represent to Lucky Bones Country Club, LLC that, to my knowledge, the above pet has not been exposed to any contagious diseases within thirty days prior to check- in. I further understand that each time the above pet is brought to Lucky Bones Country
Club, LLC I am certifying that the above pet is in good health and has not had any
communicable illness or disease of any kind for thirty days prior to check-in.
______5. I agree that if the above pet shows any signs of fleas or ticks during their stay at
Lucky Bones Country Club, LLC pet will have a flea bath administered to the pet at my expense.
______6. I recognize that there will be risks of injuries or illnesses when pets interact and co- mingle with other pets. I understand and agree that any problems or injuries which occur while staying at Lucky Bones Country Club, LLC will be treated by immediate first aid. If injuries require further treatment, the above pet may be treated by my own vet . In the event that my own vet is not available for treatment or vet is not nearby, pet will be treated at Mt. Airy Veterinarian Hospital. I agree to assume full financial responsibility for any and all expenses incurred for above pet’s treatment. Should my pet become ill while staying at Lucky Bones Country Club, LLC, I, or my emergency contact will be notified. In the event that I cannot be reached, nor my emergency contact, the staff at Lucky Bones Country Club, LLC has my permission to take my pet to Mt. Airy Veterinarian Hospital for treatment. If my pet is transported to or from Lucky Bones Country Club, LLC by its staff/employees, I will hold Lucky Bones Country Club, LLC harmless in the event of injury or accident during transportation.
______7. I acknowledge that I am fully responsible for any and all harm or damage to persons or propertycaused by my pet while staying at Lucky Bones Country Club, LLC. Also, I understand that I will be held financially responsible for any damage or harm caused to any person(s), be it employee, guests of Lucky Bones Country Club, LLC staff members, or any property of the owners. Further, I will be held responsible for any harm caused to any other pet(s) being housed or visiting Lucky Bones Country Club, LLC.
______8. I understand that all employees/staff of Lucky Bones Country Club, LLC shall exercise reasonable care for my pet. I understand that Lucky Bones Country Club, LLC’s liabilities shall not exceed the lesser of the current charter value of my pet of the same species or the sum of $400.00 per animal boarded or cared for.
______9. I accept the fact that by the above pet staying at Lucky Bones Country Club, LLC or any other facility, my pet may be at a higher risk of contracting viruses such as, but not limited to, kennel cough. Although all pets entering Lucky Bones Country Club, LLC are required to be up-to-date on all vaccines, no one vaccine is 100% guaranteed. Some strains of kennel cough may not be covered by the Bordetella vaccine. I agree to be held responsible for any and all vet bills incurred to my pet due to any illness.
______10. I understand that the above pet will be interacting and co-mingling with other pets while at Lucky Bones Country Club, LLC. While every precaution will be taken to supervise all dogs, my above pet may be removed from interacting with other pets should he/she show signs of aggression or not getting along with other pets. At any time, Lucky Bones Country Club, LLC has the right to remove the above pet from the facility due to reasons deemed necessary and not permitted to return.
______11. I further acknowledge and agree that Lucky Bones Country Club, LLC along with their staff, employees, and volunteers, will not be held liable for any problems which develop, considering reasonable care and precautions have been followed. I hereby release and discharge Lucky Bones Country Club, LLC from any and all damages, liability, accidents, or injury whatsoever arising from my above pet attending Lucky Bones Country Club, LLC.
______12. I understand that a reservation is required to hold a spot for my above pet. All forms and proof of vaccinations will be required and will be kept on file. I may cancel my reservation of above pet at least 24 hours in advance of scheduled arrival date. Lucky Bones Country Club, LLC reserves the right to charge cancellation fees for no shows.
______13. I have initialed each of the above statements and certify that everything is accurate and true and acknowledge my understanding and acceptance.
I certify that I have read, understand and agree with the policies and procedures of Lucky Bones Country Club, LLC as set forth on the preceding pages and that I have read, understand and agree with the conditions and statements of this agreement. I , my heirs, and any other assigns, hereby release Lucky Bones Country Club, LLC, its owners, employees, Subcontractors, building landlord, customers and potential customers of Lucky Bones Country Club, LLC from any and all liabilities for injuries to myself, my pet, or any other property which may occur while staying at Lucky Bones Country Club, LLC.
This written Agreement constitutes the entire agreement between the parties and there are no oral agreements or understandings except as provided for herein.
All terms and conditions of this Agreement shall be binding on the heirs, administrators, personal representatives and assignees of the Owner/Guardian and Lucky Bones Country Club, LLC.
Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, or as the result of any claim or controversy involving the alleged negligence by any party to this Agreement, shall be settled in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof. The arbitrator shall, as part of the award, determine an award to the prevailing party of the costs of such arbitration and reasonable attorney’s fees of the prevailing party. The arbitrator(s) shall apply North Carolina law to the merits of any dispute or claim without reference to conflicts of law rules. The parties hereby consent to the personal jurisdiction of the state and federal courts located in the Agreement or relating to any arbitration in which the parties are participants. The parties have read and understand this clause, which discusses arbitration. The parties understand that by signing this Agreement that they will submit any claims arising out of, relating to, or in connection with this Agreement or the interpretation, validity, construction, performance, breach, or termination thereof, to binding arbitration and that this arbitration clause constitutes a waiver of the party’s right to a jury trial and relates to the resolution of all disputes relating to all aspects of the relationship between the parties.
Signature of Owner/Guardian:______
Name of Owner/Guardian:______
(please print)
Date:______
Signature of Lucky Bones Country Club, LLC Representative:______
Name of Lucky Bones Country Club, LLC Representative: ______
(please print)
Date:______