<p> Carolina Dog Training Club, Inc. 2311 Hickswood Rd. High Point, NC 27265 336 273 8828 www.carolinadogtrainingclub.com [email protected]</p><p>Registration Application: Beginner 1 & 2, Competitive/Advanced Novice, Open/Utility For class sessions beginning January 6, 2009 FEES for 8 wk sessions: Beginner 1 Class: $90 -- Beginner 2: $55 -- Comp/Adv Novice, Rally: $50</p><p>CLASS FEES ARE NON-REFUNDABLE AFTER THE FIRST DAY OF CLASS (Jan 6) </p><p>Instructions: Complete both sides of form, and send a copy of the dog’s shot records. Return forms with check payable to “Carolina Dog Training Club”. We recommend early application - class sizes are limited. We charge a $25 fee for any checks returned for insufficient funds. AS A CONDITION OF ACCEPTANCE OF THIS APPLICATION, THE AGREEMENT ON THE REVERSE SIDE MUST BE COMPLETED & SIGNED. Handler’s name: ______Home phone: ______Mailing Address: ______Work phone: ______City/State/Zip: ______Cell number: ______</p><p>Email address: ______Dog’s sex: ______Dog’s name: ______Breed: ______Dog’s Birth Date: ______</p><p>Has your dog ever nipped at or bitten another dog? YES NO Has your dog ever nipped at or bitten a person? YES NO Has your dog ever been fearful of people or dogs? YES NO Has your dog ever been aggressive towards dogs or people? YES NO Has you dog ever lunged at or growled at another dog? YES NO Has your dog ever lunged at or growled at a person? YES NO Has you dog ever been attacked by another dog? YES NO If yes for any of the above, please describe the situation (continue on separate paper if needed): ______What do you want to accomplish in this class? ______</p><p>______</p><p>Vaccinations: Your vet should complete this section and you will need to provide a COPY of the dog’s current shot records along with this application. All students and class levels MUST provide this info. DHLP-P Date DUE: ______Bordatella DUE: ______Rabies DUE: ______</p><p>Veterinarian’s Signature:______Handler’s Signature:______</p><p>Classes (check one) Beginner 1 & 2, Comp/Adv Novice, Open/Utility (Puppy class uses a different form) _____Beginner 1 Class (circle time preference*) 7:45 p.m. OR 8:45 p.m. _____Beginner 2 & Canine Good Citizen Cert. 7:45 p.m. (prerequisite Beginner 1) _____ Competitive/Advanced Novice Class 7:45 p.m. _____Rally Class** 8:45 p.m. * If the 7:45 Beginner 1 class is full, do you want to be considered for the 8:45 class? YES NO If NO, your check will be returned, you will be given the date for the next session, and you may reapply. We recommend early application because Beginner class size is limited. **Pre-requisite Beginner 1 (not necessarily at CDTC). THE AGREEMENT ON REVERSE SIDE MUST BE COMPLETED & SIGNED. Carolina Dog Training Club, Inc. Agreement To Hold Harmless, Waiver And Assumption Of Risk I understand that attendance of a dog obedience training class is not without risk to my dog, myself, members of my family or guests who may attend because some of the dogs to which I will be exposed may render difficulty in controlling and may result in injury even when handled with the greatest amount of precaution. In addition, it is my responsibility to keep my dog current on vaccinations, but I recognize that puppies may still be susceptible to various diseases in spite of the vaccinations. I hereby waive and release the CAROLINA DOG TRAINING CLUB, INC., hereinafter referred to as the “Training Club”, its 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 caused by the action of the dog. I expressly assume the chance of such damage or injury while attending any training class, or any other function, of the Training Club or while on the training facility or neighboring area thereto. In consideration of and as inducement to the acceptance of my application for training membership by the Training Club, I hereby agree to indemnify and hold harmless this Training Club, its 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 class or function of the Training Club, or while on the facility or neighboring area thereto as a result of any action by any dog, including my own. I also understand the potential health risk in exposing a young puppy, without complete disease immunity, to other dogs. I release the Training Club from any liability relating to this. ______Date: ______Signature of Owner or Authorized Agent (in case of a minor, a parent or guardian must sign) ______Name of Owner (if different from name on reverse side) ______Street City State Zip Code</p><p>DO NOT WRITE IN THIS SPACE</p><p>Fees paid: $______Date rec’d ______Check #: ______Date of Check: ______</p><p>Vaccination record copy included: YES NO Additional information needed:</p><p>Veterinarian’s signature included: YES NO (NOT NEEDED IF VET COPY INCLUDED) Registration confirmation date: ______confirmed by (circle one): PHONE EMAIL MAIL CDTC_Appl_Form_2009 (revised 11/25/08)</p>