Betty's TLC Dog Training - Registration Form - Please choose a course from the 2010 Training Schedule!
1. Print out form
2. Fill out form completely!
3. Mail form with check or money order in the amount of *$150.00 to:
Betty’s TLC Dog Training, 126 Beacon Street, Middletown, RI 02842.
4. You will receive a confirmation in the mail once your registration is received. Directions, instructions and
equipment suggestions will be provided on your confirmation.
(All dog training courses are located and conducted at the Middletown High School in the rear field – outdoors- Rain dates are made up for free.)
First Name:__________________________________________________
Last Name:____________________________________________
Address:_______________________________City:___________________State:_____Zip:___________Phone:____________________Cell:_____________________
E-mail:___________________________________________________________
Dog's Name:____________________________________Age:________________Breed:___________________Sex:___________________Altered Male:
_______Altered Female:___________Intact Female_____
Intact Male______Age of acquisition:____________Color of dog:___________________
Dog's physical limitations:____________________________________________________
Dog's medical problems:
___________________________________________________________________________________________________________________________________________
Dog's Behavioral problems:
___________________________________________________________________________________________________________________________________________
Where did you acquire this dog (be specific)____________________________________________________
Previous training?__________________________
Where? (be specific)__________________________________________________
Instructor's name:____________________________________________________
Did you finish the training course?____________If not, why?:_________________________________________________________________
What type of training has your dog had? Circle all that apply:
Positive only positive and negative - e-collar - no training at all- trained dog myself
How is your dog confined when outdoors? List all that apply:
Invisible fence - structural fence (cannot see through) chain link - picket fence - stockade (cannot see through) tied out to fixed structure - other (explain)
_____________________________________
Has your dog ever bitten, snapped or growled? (explain on reverse of this form- include each and every incident in detail)
Is your dog aggressive with other dogs?_____Has your dog ever been attacked by another dog?_____ If yes, how many times?______Was your dog on a leash
when he/she was attacked?_______
Do you crate your dog during the day?_____How many hours a day is your dog crated at a time?_____How many hours a day is your dog home alone?_______
How many other animals does your dog live with?_________
What are they?____________/_________/_________/___________/____________
Do they coexist together or do you separate them?____________
List family members that coexist with this dog- ages, sexes:____________________________
In your opinion, What types of people and animals does your dog seem to not get along with?______________________________________ ___________
How many homes has this dog had prior to yours:_________
Does this dog have any compulsive disorders?_______________________
explain:_______________________________________________
What is your veterinarian's name:____________________________________________________
Name of your veterinarian's practice:_______________________________________________________
Veterinarian's phone number (in case of emergency):_______________________________________________________
If your dog was adopted from a shelter, please give the name and address of the shelter and the date of adoption:
_____________________________________________________________________
_____________________________________________________________________________
I am enrolling/registering for the course/seminar that begins on _______/_______/______ @ ________am/pm
I have enclosed a fee of: ____________ for the course/seminar entitled: _______________________________
............................................
Waiver/release - (Read and Sign) - No admittance without this waiver!
I understand that I must be fully responsible for my dog's behavior while on the school grounds and/or in surrounding areas of the school. I agree to hold
Betty's TLC Dog Training and the school completely harmless in the event that either myself or my dog causes pain or injury to another individual, dog or the
property while in participation at this course. I agree to be completely liable for any/all damages or injuries while in attendance with my canine. I do
understand that participation in any dog training course will not guarantee a risk free, non aggressive canine and I also release and agree to hold harmless –
Betty’s TLC Dog Training LLC - in it’s entirety while in participation at any/all training and/or specialty courses that I decide to participate in and In the event
that another participant or dog injures me or my canine, I will hold Betty’s TLC Dog Training LLC and the property in which the injury occurred, completely
harmless. I state that I am in good physical condition at the time of my enrollment into these courses. I agree to take full responsibility for my actions, health
and decisions during any/all lessons/session/events conducted by Betty’s TLC Dog Training LLC. Furthermore I am stating that I am not under the influence of
any mind altering drugs or alcohol while in participation of any of these events that I am enrolling into.
Signature of handler/owner/agent:_____________________________________Date____________
Print name:_________________________________________Date:_________________
Please make a copy of this waiver for your records!
.............................................................................................................................................................
For more information or if you have any questions before mailing this form, please e-mail me at the e-mail address below:
goldsalvage@verizon.net
or
(401) - 841-0857
Betty Laurin,
Certified Dog Behavior Consultant
Certified Professional Dog Trainer - KA
Certified Pet Dog Trainer
Clicker Practitioner
Canine Good Citizen Evaluator
Expert Shelter Dog Evaluator
Presenter/Speaker