Go Dog Social Club
Member Information and Release
|
Print out, fill out, and fax to 713-686-6134. We will then contact you.
|
YOUR INFORMATION:
Name: ______________________________ Home Phone:______________________
Address:_______________________________ Work Phone:______________________
City:___________________ Zip:___________ Cell Phone :_______________________
Email:_________________________________
VET INFORMATION: EMERGENCY CONTACT (other than vet):
Name:_________________________________ Name:_____________________________
Address:_______________________________ Phone Nos._________________________
City:___________________ Zip:___________ __________________________________
Phone:________________________________
PET INFORMATION:
Name:__________________________Breed:__________________________Age:___________
Birthday:________________________Sex: ________Color______________Spayed/Neutered?
Medical History:_________________________________________________________________
______________________________________________________________________________
Medication:_____________________________________________________________________
______________________________________________________________________________
Special Instructions:______________________________________________________________
Behavior Problems:
Has your dog been successfully socialized with other dogs?_______________________________
Has your dog been successfully socialized with adults?___________________________________
Has your dog been successfully socialized with children?__________________________________
Is your dog aggressive with strangers?________________________________________________
Please circle the following behavior issues that apply:
Dog aggressive Chews excessively Runs away High jumper
Toy possessive Stool eater People Aggressive Digs Unruly
Shy People possessive Picky eater Jumps up Barks excessively
Escapes Does not obey Separation anxiety Non-submissive Not house broken
Has your dog been in training classes and/or private lessons?____________________________
If yes, by who, when, and for how long?______________________________________________
Has your dog been to day care or socials before?______________________________________
If yes, when?___________________________________________________________________
Is there anything else we need to know about your dog?_________________________________
_____________________________________________________________________________
How did you hear about the Go Dog Social Club?_____________________________________
_____________________________________________________________________________
Do we have your permission to use photographs of your pet(s) in our website, flyers, ads, and brochures?
____________________________________________________________________________
Release
Client assumes any expense or liability for injuries that Client’s pet may inflict upon any human or other pet.
Client specifically represents to Go Dog Social Club that the pet has not been exposed to rabies or distemper.
Client releases Go Dog Social Club and The Shady Tavern, their agents, officers, subcontractors, and employees, as
well as other animal owners, customers, and potential customers from any and all liability for injuries to yourself, your
pet, or any other property, which arise in any way out of services provided by or as a result of your association with
Go Dog Social Club and/or The Shady Tavern. Client understands that there are certain risks involved with pet
ownership, training, and care, including, but not limited to, fights, bites, illness, and the transmission of disease.
By signing below, the Client acknowledges and accepts responsibility for these and all other risks, and releases Go
Dog Social Club and The Shady Tavern from any liability for injuries or illness.
Client Name:_____________________________
Client Signature:___________________________
Date:_____________________________________