Ultimate Companions Course Application

Please provide the following information:

Course (select 1)	Kindergarten Middle School High School Come Here! Yes, I Mean Now Canine Good Citizen/College Level
Preferred Locations	Putney Williston - The Pet Lodge South Burlington - The Crate Escape Richmond - The Crate Escape
Second Preferred Location (if any)	Putney Williston - The Pet Lodge Richmond - The Crate Escape South Burlington - The Crate Escape I will only go to my first location I will go to any location
Requested Start Date
Days/Time Available (check all that apply)	Mon AM  PM Tue AM  PM Wed AM PM Thu AM  PM Fri AM PM Sat  AM  PM Sun AM   PM
Name (please print as you want on graduation certificate)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Dog's Name
Breed
Dog's Birthday
Sex	Intact Male Neutered Male Intact Female Spayed Female
How did you hear about us?
Where did your dog come from?
How old was your dog when you got it? (if you are not dog's first owner, please describe dog's history as you know it
Have you trained a dog before?  If so, when and where?
Please check any areas of concern:
Barking Chewing Jumping Up House soiling Nipping Not Coming Growling Biting Afraid of Thunder Afraid of Kids Afraid of Men Afraid of Other Dogs
Has/Does your dog played/play with other dogs?  Please explain
What are your goals for class?
What family members will be attending class?  (all welcome)
On a daily basis, what does your dog do for exercise?
MEDICAL INFORMATION (Please complete this section fully or we will not be able to process your application.  All dogs must be vaccinated for Distemper, Parvo and Canine Cough.  The first Rabies shot is good for ONE year.  Subsequent ones are good for THREE years.  Puppies must be started on Distember/Parvo series and had Canine Cough to attend class.  *PLEASE SEND A COPY OF PROOF OF VACCINATIONS OR BRING IT TO THE FIRST CLASS)
Name of Veterinarian:
Date of Last Distemper/Parvo:
Date of Last Canine Cough (optional)
Date of Last Rabies
I hereby waive and release Bill Grant/Ultimate Companions, it’s employees, officers, members and agents from any and all liability of any nature for injury or damage which I or my dog may suffer, including specifically, but without limitation, 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 or while on the training grounds or the surrounding area thereto.  In consideration of and as inducement to the indemnify and hold harmless Bill Grant/Ultimate Companions and it’s employees, officers, members and agents from any and all claims or claims by any member of any family or any other person accompanying me to any training session or function fo Ultimate Companions or while on the grounds or the surrounding area thereto as a result of any action by any dog, including my own.
I have read the above and understand:(please type full name)
*Please remember to forward payment prior to class start date. Payments should be sent and made out  to: Bill Grant P.O. Box 848 Putney, VT  05346 Course fees are $130.00 for a six week session and 100.00 for the 4 week Come Here class