Buster and Lilly Membership Application

Full Name *

First Name Last Name

Full Name

First Name Last Name

E-mail Address *

E-mail

Daytime Phone # *

Evening Phone #

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Name *

Breed *

Sex *

Male Female

Age *

Birth Date (If Known)

Month Day Year

Spayed/Neutered *

Name

Breed

Sex

Male Female

Age

Birth Date (If Known)

Month Day Year

Spayed/Neutered

Clinic/Hospital Name *

Phone Number *

- Area Code Phone Number

Upload your vaccine history here:

Full Name (Someone other than you) *

First Name Last Name

Phone Number *

- Area Code Phone Number

Who is Authorized to Pick Up Your Dog From Buster & Lilly's?

How Did You Hear About Us?

Source *

1. All dogs must be dog-friendly and people-friendly. They must be non-aggressive and non-protective of food and toys. If we determine at any time that a dog’s behavior is aggressive, we reserve the right to dismiss him/her from daycare at our discretion.

2. If your dog eliminates on the grounds outside of Buster & Lilly’s, please clean up and deposit in the appropriate receptacles.

3. All dogs must arrive and leave on a leash and wearing a flat, leather or nylon, quick-release collar with tags. Buster & Lilly’s personnel may remove the collar for safety reasons.

4. All dogs must be in good health, spayed or neutered, physically sound and adequately protected from disease. Any dogs receiving a Bordatella Inter-nasal immunization may not come to Buster & Lilly’s for the following week and if symptomatic until all symptoms subside.

5. All dogs must be relatively clean, brushed, and flea free.

1. In consideration of being permitted to use the services and facilities of Buster & Lilly’s, I/we, the undersigned owner(s), hereby release, waive and discharge Buster & Lilly’s, its shareholders, staff, sub-contractors and volunteers from all liability for any and all loss or damage, and any claim or damages resulting there from, on account of injury, loss, damage, ailment or disease to my/our dog(s), even resulting in death, while my/our dog(s) is/are under the care of Buster & Lilly’s.

2. I/we agree to indemnify Buster & Lilly’s, its shareholders, staff, sub-contractors and volunteers for any loss, liability, damage or cost they may incur due to my/our presence or the presence of my/our dog(s) in or upon Buster & Lilly’s premises and while my/our dog(s) is/are under the care of Buster & Lilly’s

3. I/we hereby assume full responsibility for any harm or damage caused by my/our
dog(s) while in or upon Buster & Lilly’s premises and while my/our dog(s) is/are under the
care of Buster & Lilly’s. I/we further agree to indemnify Buster & Lilly’s, its shareholders, staff,
sub-contractors and volunteers for any loss, liability, damage or cost they may incur due to any harm caused by my/our dog(s).

4. I/we expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State of Oregon, and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.

5 . I/we further understand and agree that in admitting my/our dog(s) to Buster & Lilly’s, the operators of Buster & Lilly’s have relied on my/our representation that my/our dog(s) is/are in good health and has/have not harmed or shown aggression or threatening behavior toward any person or any other dog.

6 . I/we further understand that any problem, including but not limited to injury and illness, that develops with my/our dog(s) will be treated as deemed best by the staff of Buster & Lilly’s, in their sole discretion, and that I/we assume full financial responsibility for any and all expenses involved, and that I/we hereby agree to indemnify Buster & Lilly’s, its shareholders, staff, sub-contractors and volunteers for any expenses incurred for such treatment.

7. I/we understand that all fees are non-refundable for any reason.

8. I/we have read and understand the attached Rules and Regulations and Cancellation Policy and agree to abide by them.

9. I/we accept all the terms, conditions and statements of this Agreement and Release.

* Payment is expected at the time of service. 5% interest will be added to invoices over 30 days. Invoices past 90 days will go to collections *

This will serve as your agreement to the Rules and Regulations as well as the Daycare Agreement & Release *

I agree

Today's Date *

- Month - Day Year

Name *

First Name Last Name

Owner(s) Information

Dog Information

Vet Information

Emergency Contact

Rules and Regulations

Daycare Agreement & Release