Obedience & Performance Training Class - Registration Form

Meredith Community Center

One Circle Drive, Meredith, NH 03253

(Please Print)

Class Information:

Please check off which class or classes that you would like to attend.

AKC STAR Puppy 6-7 PM (One Dog) < > Rally O 6-7 PM > Competition Novice Obedience & Open Preparation 7-8 PM Nosework 7-8 PM

Please tell us where you heard about our classes? ______

Have you taken classes with LRKC before? Yes__Class______No___ With this dog? Yes___No__

Owner Information:

Owner(s) ______Handler (s)______Guest/s______

(First name) (Last name)

Physical & Mailing Address______

City______State______Zip______

Telephone #______Cel #______Email______

Would you like to receive our club newsletter? > Yes, (Please Provide Legible E-Mail) < >No thanks

Dog Information:

Dog’s Name______Breed______AKC #______

Date of Birth ______Sex______Altered? >Yes >No

How long have you had this dog? ______

Has the dog bitten anyone? > Yes > No

Does the dog show any aggression? > Yes > No

If YES, please describe ______

Dog’s Medical Information:

Veterinarian’s Business Name______

Address ______Telephone ______

REQUIRED:

Rabies Certificate # ______or Town Tag # ______Expiration Date _____ Puppy appointment date______

Vaccinated for Kennel Cough (Bronchine) * Suggestion only: Yes____Date______NO _____

Name of Veterinarian who administered the vaccine______

Describe any physical condition your dog has which might interfere with its training. ______

General Information:

Are there any particular problems? ______

In case of emergency, contact ______Telephone # ______

*Proof of currant RABIES VACCINATION mandatory for all classes.

PLEASE READ AND SIGN LIABILITY CLAUSE

Release from Liability:

I______, understand that attendance at a dog training class, practice, match or gathering of dogs of any kind is not without risk to myself, my dog, members of my family or guests who may attend, due to some of the dogs to which I, (we) may be exposed to, may be difficult to control, may have an unpredictable behavior and despite the appearance of being healthy and handled with the greatest amount of care, may still be the cause of injury.

I hereby waive and release the Lakes Region Kennel Club, Inc. and the Meredith Community Center, its members, staff, instructors, trainers, assistants and volunteers from any and all liability of whatsoever nature or kind of injury or damage, which I or my dog may suffer, including any injury, death, theft or property damage resulting from the action of any dog or my own. I expressly assume the risk of such damage or injury while attending any training session or other function in the building or while on the training grounds surrounding the area of the Meredith Community Center or surrounding area thereto as a result of any action by any dog including my own.

Owner’s Signature______Date______

Must be over 18 years of age. Parent or guardian must sign for minor-junior handler and accompany minor-junior handler AT ALL TIMES.

Location: Meredith Community Center. Please enter and exit using the Activity Center door by the children’s playground. Watch for signs.

Class Fees: $85.00 (Full 7 weeks includes testing) Amount ______

NO REFUNDS

Walk In Fee:

For Obedience/Rally & Breed Handling classes only. $15.00 per dog.

Training Collars: $10.00 each ______x ___ Amount ______

(Collars may be exchanged at any time)

Six Foot Leash: $10.00 each ______x ___ Amount ______

Combo Collar & Leash $18.00______x____ Amount ______

Payment : Cash ___ Check #______Rec. by:_____Amount ______

(Please make checks payable to LRKC)

Total______

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If registering in advance, mail to: LRKC, PO Box 752, Meredith, NH 03253

Questions? Call Linda, 848-7149 or email:

4/2014