NAME: ______________________________ AGE: (if under 18)__________________

ADDRESS: Street___________________________________________________________

City/State/Zip____________________________________________________________

E-mail: __________________________________________________________________

Home phone: _________________________Work phone: ________________________

NAME OF DOG: ____________________________________________________________

BREED: __________________________________________________________________

AGE OF DOG: ___________________ SEX OF DOG: Male/Female Neutered/Spayed

How long have you had your dog? ____________________________________________

Where did you obtain your dog?     Breeder       Pet Store              Shelter                 Private Adoption

Other (Please specify) ______________________________________________________________________________

Veterinarian: ________________________________________________________________

Class desired: _______________________ Location & Time:_______________________________

Have you trained before?_____ If yes, when and where?___________________

_______________________________________________________________________

If yes, what breed(s)? _____________________________________________________

Have you owned a dog before?     Yes      No

Have you trained a dog before?      Yes      No

How did you learn about our classes?

Briefly state what you hope to accomplish in this class:

_________________________________________________________________________

_________________________________________________________________________

I hereby waive and release the Danbury Community Center and Lana Pettey, hereinafter referred to as the "Training Organization," its 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 to 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, of the Training Organization, or while on the training grounds or the surrounding areas thereto. In consideration of and as an inducement to the acceptance of my application for training membership by this organization, I hereby agree to indemnify and hold harmless this Training Organization, its employees, officers, members, and agents from any and all claims, or claims by any member of my family or any other person accompanying me to any training session or function of the Training Organization, or while on the grounds of the surrounding area thereto as a result of any action by any dog, including my own.

Signature of Owner or Authorized Agent:

(In case of a minor, a parent or legal guardian must sign.)

__________________________________________________________
(Signature)

__________________________________________________________
(Date)

__________________________________________________________
Name of Owner (if different from handler)

Please sign and mail with deposit of $30 to

L. Pettey
29 Lilac Lane
Danbury, NH 03230