Evaluation Information/Registration Form

Owner's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Work Phone Number

Area CodePhone Number

Email*

example@example.com

Dog's Call Name (the name used when you call them to you)?*

Breed*

What is your dog's weight?*

5 - 15 lbs35 - 50 lbs50-90 lbs90 lbs >

What is the Date of Birth of the dog?*

How long have you owned your dog?*

Sex of Dog*

MaleFemale

Is your dog Spayed/Neutered*

YesNo

If your dog has an AKC Registration, PAL Registration, or Canine Partner Registration with the American Kennel Club (AKC), enter the registration number.*

If your dog is registered by the AKC, what is the exact name of the DOG on the Registration Certificate?*

Shots/Vaccines:

Shots Needed: ParvoVirus, Rabies, Bordetella (needed every six (6) months),
Distemper, Adenovirus Type 2, Canine ParaInfluenza.

Shot Records: Shot Records, from the Veterinarian, will be required below as proof.

Date of Last Rabies Shot*

Was this a 1 year or 3 year Shot? (Please email a copy of the Rabies Vaccination Certificate, NOT INVOICE, to: info@whitehavencanine.org )*

1 year3 year

Who is your veterinarian?*

What is your veterinarians' phone number?*

Did you get your dog from a Breeder or a Shelter/Rescue Organization? If from a Shelter/Rescue, please state the name of the Shelter and the city of the Shelter.

1) Does your dog show any type of aggressive behaviors? and 2) Has your dog ever bitten another dog or human. Explain in detail.*

Please list any Formal Training your dog has completed.*

When are you wanting the Evaluation?*

Which Evaluation are you needing?*

CGCCGCACGCUOther

LIABILITY WAIVER

I understand that all dogs participating in Evaluations must be free of any infectious disease and must be current on all appropriate vaccinations, including bordatella, distemper, parvovirus and rabies. (Proof of vaccinations WILL be required)

I grant permission to use me and my pet’s photograph(s) and/or video(s) taken during evaluations for educational and promotional purposes in any type of media.

I must be at least 16 years old or accompanied by a legal guardian to participate in any evaluation.

Electronic Signature*

First & Last Name

Date*

How did you hear about our services? If referred to us by someone, please state who referred you.*

Please verify that you are human*