Community Dog Visiting Team Application Form

Owner Information

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

How Did You Hear About Us?*

How Many Children Do You Have?*

Have You Ever Owned A Dog?*

Have You Ever Trained A Dog?*

Briefly State What You Hope To Accomplish In This Class:*

Dog Information

Dog's Name*

Breed*

Age*

How Old Was The Dog When You Acquired It?*

Gender*

MaleFemale

How Long Have You Owned The Dog?*

Has Your Dog Been:*

SpayedNeuteredNone of the Above

Where Did You Acquire Your Dog?*

Where Does Your Dog Sleep At Night?

Is Your Dog House Trained?

Behavior Problems Of Parents Or Littermates, if Known?

Veterinary Information

Veterinarian

Vet Clinic

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is Your Dog Current On All Vaccinations *

YesNo

Vaccination Dates:

C5*

Please List All Medications Your Dog Is Currently Taking. Please Include Heartworm, Flea and Tick Medications, etc*

Please List Any Medical Problems Your Dog Has Had:*

Behavior Information

Describe Any Previous Obediance Training:

Level Of Success?

What Commands Currently Work Best?

Which Member Of The Family Has The Best Control?

Does Your Dog Know How To Walk On A Leash?*

YesNo

How Does Your Dog Respond To The Following Tasks?

Trimming Nails?*

Giving Pills?*

Cleaning Ears?*

Grooming?*

Bathing?*

Patting Head?*

Grasp Collar?*

Being Lifted?*

Rolling Over*

Tell Me About Any Correction Techniques You Have Used And Their Effect On Your Dog’s Behavior:

Time Out*

Leash Correction*

Verbal Scolding*

Noisemaker*

Water Spray*

Rollover*

Other*

Other Description, If Needed:

Behavior Problems:*

Describe Unwanted Behavior In Greater Detail:*

Describe How Your Dog Reacts To The Following Times When Left Alone:

During The Day:

During The Evening:

What Is Your Dog's Reaction To Your Departure?*

What Is Your Dog's Reaction To Your Homecoming?*

Do You Use A Crate?*

YesNo

Does Your Dog Like The Crate?*

YesNo

Does Your Dog Exhibit Any Of The Following Behaviors, and When Does It Occurs (With Men Or In The Car)

Cowering

Ears Back

Tail Tucked

Retreating

Hiding

Excessive Salivating

Pacing

Please Give Additional Information Regarding Fear Or Anxiety In Your Dog:

Describe Situations Where Your Dog Appears Fearful And/Or Aggressive:

Do You Ever Muzzle Your Dog For Safety?*

YesNo

Is Anyone In Your Family Afraid Of Your Dog? If So, Please Describe:*

How Does Your Dog Respond To The Following Situations?

When Approached While Eating:*

When Approached With Treat Or Toy:*

When Dog Is Scolded:*

When Dog Is Pushed Off Furniture Or Bed:*

When Dog Is Approached While Sleeping:*

To Strangers Outside Of The House:*

To People Entering House/Yard:*

To Children Or Infants:*

While In Car To People Outside Of The Car:*

To Other Dogs In Your Home:*

To Other Dogs Outside Your Home:*

Ever Aggrieve To Family Members?*

YesNo

Has Your Dog Ever Bitten A Person?*

YesNo

Has Your Dog Ever Been Reported To Animal Control For Biting?*

YesNo

NO REFUNDS - NO CLASS CHANGES

AGREEMENT TO HOLD HARMLESS, WAIVER AND ASSUMPTION OF RISK

I understand that attendance of a dog temperament evaluation is not without risk to myself, members of my family or guests who may attend, or my dog, because of some of the dogs to which I will be exposed may be difficult to control and may be the cause of injury even when handled with the greatest amount of care.

I hereby waive and release Therapeutic Dog Services hereinafter referred to as the "Evaluation Organisation", its employees, officers, members and agents from any and all liability of any nature, for injury or damage which I or my dog may suffer, including specifically, but without limitation, any injury or damage resulting from the action of any dog, and I expressly assume the risk of such damage or injury while attending any training or evaluation session, or any other function, of the Training Organisation, or while on the training grounds or the surrounding area thereto.

In consideration of and as inducement to the acceptance of my application for Therapy Dog training registration by this Training Organisation, I hereby agree to indemnify and hold harmless this Training Organisation, its employees, officers, members and agents from any and all claims, or claims by any member of any family or any other person accompanying me to any training session or function to the Training Organization, or while on the grounds or the surrounding area thereto as a result of any action by any dog, including my own.

By Clicking The Submit Button You Agree To The Above Terms

Photo of you and your dog

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Upload a copy of your dogs vaccination records

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Why would you like to become a community visiting dog team?