SOUTHERN MARYLAND DOG TRAINING CLUB OF FORESTVILLE, INC. CLASS ENROLLMENT FORM Puppy Course $60 ________ Basic Course $60 ________ Novice Course $75 ________ Owner Information Owner’s Name _________________________________________________________________ Address ______________________________________________________________________ City/State/ZIP __________________________________________________________________ Home Phone ____________________ Work Phone ___________________________________ Email Address _________________________________________________________________ Dog Information Dog’s Name _____________________ Breed ________________________________________ Date of Birth/Age _______________________________________________________________ Weight _______ Sex _______ Spayed/Neutered ______________________________________ Referred by ___________________________________________________________________ Where did you get your dog? ______________________________________________________ Is the dog house trained ____________________ Crate trained __________________________ Is your dog crated on a schedule for naps, rest periods, etc? _____________________________ How long is the dog left alone each day? ____________________________________________ Where is the dog when you’re not at home? __________________________________________ Where does the dog sleep at night? ________________________________________________ Is this your first dog? If not, please describe__________________________________________ _____________________________________________________________________________ Has this dog had prior training and if so, where/when? __________________________________ _____________________________________________________________________________ Has this dog ever bitten a person ________________Another dog ________________________ Describe circumstances of bite(s) __________________________________________________ _____________________________________________________________________________ What specific things are you hoping to learn in this class? _______________________________ _____________________________________________________________________________ Please circle any of the following problems that apply to your dog: Chewing Going into trash Jumping on people Leash pulling Digging Won’t come when called Barking Growling Mouthing (play biting) Biting Other behaviors _________________________________________________________ Please circle any of the following that describe your dog’s temperament: Friendly Easily distracted Hyperactive Mellow Stubborn Confident Playful Affectionate Aggressive toward people ____ other dogs _____ Shy with men _____ women _____ kids _____ other dogs _____ Vaccination/shot record checked by ________________________________________________ Check attached? Yes ____ Amount _________ Balance due? ___________________________ Please read and sign (if under 18, a parent or guardian must sign) I certify that I will hold harmless the Southern Maryland Dog Training Club of Forestville, Inc., and all persons connected therewith in any capacity whatsoever, from any and all liability, cost, and expense for any injury or damage to persons or property, caused by any dog brought by myself or anyone to the training class and any and all events held or sponsored by this Club. I realize that dog behavior can be somewhat unpredictable. SMDTC recommends that I obtain liability insurance through a homeowner’s policy or tenant policy. Signature Date Make all checks/money orders payable to: SMDTC. Mail check and enrollment form to: Linda Ciampo, 14901 Wannas Drive, Accokeek, MD 20607.