15 Cross St.* Norwalk, CT 06851 * PHONE 203-838-7729 * FAX 203-838-7763
CLASS REGISTRATION FORM
PLEASE PRINT AND THEN MAIL THIS FORM ALONG WITH THE:
Dog's vaccination records (including Bordatella)
Copy of the dog's license
Payment
TO THE ADDRESS ABOVE.
Owner’s Name ______________________________
Street ______________________________________
City _________________________ State ____ Zip _______________
Home phone ___________________
Dog’s Name ______________________ Age ______ Breed ______________
I am registering for the ______________________________ class
Which meets on ___________________
Beginning on ___________________
Puppy class- $165.00 | Foundation 1 $185.00 | All other classes - $165.00
Enclosed is my payment in the amount of $______________.
Check No. ___________
Signature_________________________________________________________
Payment must be made in full – please read make-up and refund policies carefully.
YOUR DOG MUST BE CURRENT ON ALL VACCINATIONS AND MUST HAVE BEEN INOCULATED FOR KENNEL COUGH WITHIN THE LAST YEAR.
PLEASE PROVIDE A COPY OF VACCINATION RECORDS AND LICENSE EACH YEAR.
WE ARE REQUIRED BY LAW TO HAVE A COPY OF YOUR DOG’S LICENSE ON FILE.
PLEASE READ THE FOLLOWING RELEASE FORM.
YOU WILL BE REQUIRED TO SIGN A COPY AT THE FIRST CLASS.
Dog Owner Release Contract
This is a contract between Dog Gone Smart and the dog owner whose signature appears below.
1.Dog owner agrees to pay the rates for all services in effect on each date the pet is checked in.
2. Dog owner recognizes that while in the care of Dog Gone Smart, the dog will interact with other dogs and humans. This interaction creates a risk of injury or illness to the dog owner’s dog and to others. The dog owner assumes all risk, liability, and expenses for such exposure and interaction.
3. Dog owner further agrees
to pay for any special services requested and for any veterinary costs
incurred while the dog is in the care of Dog Gone Smart. Special services are
as follows; walks outside, individual playtime with a staff member, swim
lessons, supervised swim, therapy, and any grooming services.
4.
Dog owner
will not hold Dog Gone Smart or anyone associated with them liable for injury to
persons or property caused by their dog or any dog brought by them. Nor will dog
owner hold Dog Gone Smart liable for physical harm which might come to them or
their dog while on the premises of Dog Gone Smart.
5. By signing this contract and placing the dog in the care of Dog Gone Smart, the dog owner certifies that he/she has provided full and accurate information about the owner and dog including all vaccination records to Dog Gone Smart.
6. If swimming for therapy, dog owner has provided Dog Gone Smart with a written prescription and release from a licensed veterinarian.
7. Dog owner assumes all responsibility for the dog and the dog’s health while it is in the care of Dog Gone Smart.
8. Dog Gone Smart shall exercise reasonable care for the dog at all times the dog is in its care. It is expressly agreed that Dog Gone Smart’s liability shall not exceed the current chattel value of a dog of the same age and breed left at Dog Gone Smart. Dog owner further agrees to be solely responsible for any and all acts of behavior of said dog while in the care of Dog Gone Smart.
9. Dog owner specifically represents that he/she is the sole owner of the dog, free and clear of all encumbrances and liens.
10. If the dog becomes ill or if the state of the dog’s health otherwise requires professional attention, Dog Gone Smart, at its sole discretion, may engage the services of a veterinarian or administer medicine or give other requisite attention to the dog and the expenses thereof shall be paid by the dog owner. The dog owner gives consent to Dog Gone Smart to act in dog owner’s behalf in obtaining emergency or other veterinary care at dog owner’s expense if deemed necessary by Dog Gone Smart or any of its employees. Dog owner indemnifies and holds the facility harmless for said expenses.
11. All charges incurred shall be payable at the time of pick-up of the dog. Dog Gone Smart is hereby granted a lien on the dog for any unpaid charges deriving from services provided by Dog Gone Smart or associated costs.
12. This contract contains the entire agreement between the parties. All terms and conditions of this contract shall be binding on the heirs, administrators, personal representatives, and assigns of the dog owner and Dog Gone Smart.
Dog Owner's Signature_________________ Date__________
T I P P E C A N O E C A N I N E C E N T E R L L C