New Bern Therapy Dog Training & Certification

New Bern Therapy Dog Training & Certification

All fields marked with * are required and must be filled.
Owner's Name*

First NameLast Name
Contact Cell Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dog's Call Name: Used when you call them to you?*
Dog's Breed*
Dog's date of birth*
How long have you owned the 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 AKC registration number.*
If your dog is registered by the AKC, what is the exact name of the DOG on the Registration Certificate?*
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: NewBernTherapyDogs@yahoo.com*

1 year3 year
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?*

CGCCGCACGCULeash Walking ClassLove on a Leash Therapy DogBright & Beautiful Therapy Dog
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 rabies vaccination 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.
Signature*

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Date*

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