Application Form

Your Name
Address
City
State
Zip Code
Home #
Work #
Fax #
E-Mail Address
What is your occupation?
Other

Select Class Type

Obedience Puppy Obedience Beginning Class Obedience Advanced Class AKC Competition Novice Agility Beginning Agility Intermediate Dancing with Dogs
Date Preferred:
Where did you hear of class?
What are your goals?

About Your Dog

Dog Name
Breed
AKC#
Sex	Male Female
Altered/Spayed	Yes No
Date of birth
Veterinarian
Prior Obedience or Agility Class or Degree on dog

Innoculations

Rabies
7-Way Shots
Bordetella
Heartworm	Yes No Brand
Is your dog microchiped?	Yes No Brand

Student Questionnaire

How long have you had this dog?
Dog was acquired from
We have
My dog spends most of his time
Is your dog reliably housetrained	Yes No
My dog spends the night
My dog is fed
What brand of food do you feed?
If your dog has food allergies or other medical conditions, please list the foods that he is NOT allowed to eat:
What behaviors, if any, does your dog do RELIABLY on cue?
Please list anything your dog is afraid of
List 3 behaviors you would like your dog to learn	1: 2: 3:
If your dog has any behavior problems that are not addressed in this questionnaire, please describe them such as
Notes

Other Training

Have you attended other training with this dog?	Yes No
Trainer
What did your dog learn in the class?

Waiver Agreement

I certify that I will hold harmless any and all persons connected in any capacity whatsoever in regards to the Agility Classes from any and all liability, cost, and expense for any injury or damage sustained by or to myself, or by or to my dog(s). I also certify that there will be no legal liabilities held against Stu & Sherry Galka or Mother Lode K9 Training, or damage sustained by me or my dog(s) or any family or other person accompanying me to any training session caused in connection with the Agility Class. I understand and authorize all dishonored checks plus a $15 CA processing fee to be debited from my account. Please indicate your acceptance of this agreement by typing your name in the box below.
Signed

The Class Fee is $85
No Refunds After Lesson #2
$10 Multiple Dog and Multiple Class Discounts Available

Make checks payable to: Sherry Galka

To register please submit full payment with your application. Send to:

Sherry Galka, c/o Mother Lode K9 Training
14801 Lakeside Dr., Sonora, CA 95370
(209) 532-9217