Nildan M. Atkay, Cpdt-Ka, Abcdt

NILDAN M. ATKAY, CPDT-KA, ABCDT

Z&E Canine Manners Dog Training & Behavior

www.zecaninemanners.com

843-697-6808

‘PEOPLE’ REACTIVE DOG - REGISTRATION REQUEST

Name:

Address:

Phone:

Email:

Dog: Age: Breed:

Neutered/Spayed:

Obtained from: At age:

Behavior History

My dog has bitten people:

How many times: How many people:

Relation:

What age did the behavior start?

What have you tried to address it?

Has the behavior gotten better or worse?

Bite Analysis (Put X for all that apply)

[ ] Scraped or nicked, no bleeding

[ ] Scraped or nicked, caused bleeding

[ ] Punctured through clothes

[ ] Punctured on bare skin

[ ] Individual needed medical attention, with stitches

[ ] Individual needed medical attention, but no stitches

[ ] Law enforcement has filed bite report:

How many reports? Counties:

[ ] We have liability insurance for our dog with: (company name)

My dog knows basic commands: [ ] Sit [ ] Down [ ] Stay [ ] Come

[ ] Leave It

My dog and I have taken classes before:

[ ] Puppy Class: What Age? With whom?

[ ] Manners/Obedience Class: What age? With whom?

[ ] Reactive Dog Class: What age? With whom?

[ ] Other:

[ ] No, we have not

My dog and I have done private training with a professional before:

Age: Trainer:

Age: Trainer:

Age: Trainer:

[ ] No, we have not

Payment

Please mail in your registration form and waiver with your check prior to the start of classes. Make check payable to Nildan M Atkay

Mail to: Z&E Canine Manners, P.O. Box 12123, Charleston, SC 29422

WAIVER

Classes are filled on a first-come, first-served basis. A spot will not be held until payment is received along with signed Training Agreement and Waiver. These items must be received prior to commencement of first class.

SERVICES PROVIDED: Classes are taught by Nildan M Atkay (“Trainer”), a professional dog trainer. Classes are limited to no more than 4 dogs for safety and personal attention. Trainer, at his/her discretion, may refuse entry to any dog that is deemed unsuitable for the services provided, or owner who is unable or unwilling to follow the Trainer’s instructions necessary to maintain a safe and successful class environment.

REMOVAL FROM TRAINING: Trainer, at his/her sole discretion, may remove a pet from class if a hazard or threat of any nature to any other animal or person is present. No refund will be given under such circumstances.

PAYMENT: Payment is due prior to the start of classes. No refunds will be given after class has commenced.

CLEANLINESS: Owner is responsible for the removal of excrement that their pet is responsible for.

LIABILITY: Owner agrees to indemnify and hold Z&E Canine Manners and Trainer Nildan M Atkay and Trainer’s employees, agents, family harmless from all liability, monetary or otherwise, for any loss, damage or injury to persons, animals or property arising from or related to Owner’s pet. Owner agrees that Trainer shall not be liable for loss or damage to animal for any reason.

AGREED TO: AGREED TO:

Nildan M Atkay ______

(“Trainer”) Date Owner Date