Taking it to the Streets Class

Registration Form

 

Preferred Start Date: _______________ 

 

About You

First Name: _________________________ Last Name: _________________________________

Street:___________________________________ City: _________________________________

State:_______ Zip:________ E-mail:_________________________________________________

Home Phone: ______________Work Phone:_______________ Cell Phone:____________________

Please note if you have any physical limitations to help us meet your needs (optional): _________

______________________________________________________________________________

About Your Furry Friend     

Name:______________________________________ Birthday: ___________  Sex:_______________

Breed (give it your best guess): _______________________________Spayed/Neutered?________

Where did you get the dog?:_____________________________When?______________________

How does the dog get along with other animals?____________________________________

Has the dog ever bitten anyone? _______ If so, explain the circumstances, if it was reported,

and severity of the bite, i.e. teeth touched but no wounds, teeth scratched, puncture wound.

_______________________________________________________________________________

Please explain your training goals:

______________________________________________________________________________

______________________________________________________________________________

List some positive aspects of living with your animal companion.__________________________

______________________________________________________________________________

 

Payment Information:  

Class is $60.  Payment must be sent with registration. Check and cash only.  Sorry, no on-line or phone registrations accepted.  Space is reserved based on date registration and payment is received.  Cancellation must occur a week prior to the start of class to receive a full refund.  No refunds will be given once class begins. 

 

(  ) Check Enclosed     Please make checks payable to Center Hill School.

  

 

Mail registration, copy of shot records, and payment (checks made out to Center Hill School) to:  

               Center Hill School

c/o Training Classes

3682 Bybees Church Road,

Palmyra, VA 22963

Proof of Rabies, Distemper and Parvo vaccines are required.

Please mail a copy of the dog’s shot records with your registration.

By signing below, I (we) certify the abovementioned dog has had all vaccines required by law. To the best of my knowledge, he/she is free of communicable disease. I (we), the undersigned, also hereby agree that Center Hill School and all its employees and agents will not be liable for any damage or loss resulting from my (our) participation in this or any other class. The dog’s behavior now and in the future is solely my (our) responsibility. Should any behavior on the dog’s part now or in the future result in damage to the property, owners, or person or property of some third party, I (we) agree to assume full responsibility for any and all such damage, and to absolve Center Hill School and its employees and agents from any and all obligations to pay such damage to owner/handler or third party. 

All adults participating in class must sign below.  Children are welcome, but must be kept by your side at all times.

Signature:­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________            Date:_____________________

Signature:­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________            Date:_____________________

Photo Permission:

 

Center Hill School is so excited about the accomplishments of our students.  We like to share our pride with the community via our website and the media and would be honored if you would allow us to use your picture and any picture of your family (including children and dogs).  Using images of our students shows the community that training is the key to enhancing the human-animal bond, hopefully encouraging others to train their dogs. 

 

Please sign below to show you would like to join us in spreading the word about the importance of training to create wonderful canine citizens in our community.

 

______I do give permission to Center Hill School to include my or my family’s image as we participate in a class.

______I do not give permission to Center Hill School to include my or my family’s image as we participate in a class.

 

Signature:  ___________________________   Date:________    Signature:___________________________Date:________