Client Registration

581 West Chestnut St, Hanover, PA 17331 717-632-1111
Everything with a * is required to submit the form
Owner's Name *

First NameLast Name
Occupation*
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In Case Of Emergency Contact Information*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?*
Dog's Name*
Date of Birth*
closest guess if unknown
Breed and Weight/Size*
Sex*

MaleFemale
Fixed*

YesNo
Where did you get your dog?*
How much did you pay?*
How old was your dog when you obtained him/her?*
Physical Description (color/markings)*
Training Course*

Day Train 2 weeksDay Train 4 weeksDay Train 6 weeksBoard and Train 2 weeksBoard and Train 4 weeksBoard and Train 6 weeksPackage of Private sessions- (Location- Stateline Canine)Behavior Modification 4 weeksBehavior Modification 6 weeksHybrid 2 weeksHybrid 4 weeksHybrid 6 weeks
Behavior Problems (check all that apply)

jumps upnuisance barkingnipschewseats foreign objectshowlspulls on leashdisobeysunrulyshyaggressiveruns away
Escape Behaviors*

Door dartingFence jumping/climbingSlipping out of leash, collar, harnessDigging under fences
Has your dog ever growled, snapped, or bitten you or anyone else?*

YesNo
If yes, please specify
Does your dog get nervous around strangers?*

YesNo
If yes, please specify
Has your dog ever shown aggression towards other dog?*

YesNo
If yes, please specify
Has your dog played with other dogs?*

YesNo
If yes, please specify. i.e. multiple dogs, one other dog, etc
Does your dog ever get mad at you or do anything spiteful?*

YesNo
If yes, please specify
Does your dog get upset when you leave him/her alone?*

YesNo
If yes, please specify
Do you ever confine your dog away from you while you are home and awake?*

NoYes, crateYes, room/areaYes, outside
Do you confine your dog when you leave?*

NoYes, crateYes, roomYes, outside fence or kennel run
Is your dog comfortable in a crate?*

Yes. A vari-kennel (plastic crate)Yes. A wire crateNo; whines, cries, barks, etc.No. escapes or damages crate or themself trying toMy dog has never been cratedIt has been awhile since my dog has been cratedMy dog is only secure in a 'escape proof' crateOther
Do you allow your dog off leash?*

NoYes, fenced yardYes, yard with no fenceYes, other fenced areas (such as a dog park)Yes, areas with no fence (park, beach, etc)
Do they come when called?*

AlwaysNeverOnly when there are no distractionsYes,unless there are heavy distractions
How do you discipline your dog when they disobey/misbehave? Does it work?*
Does your dog live in the house? If not, where/why?*
Is your dog allowed on furniture?*
Is your dog allowed to sleep in your bed?*

NoSometimesAlways
Does your dog show aggression or fight you when you move them off of furniture, groom or crate them?*
How much AEROBIC exercise does your dog receive on a regular basis? What kind?*
What kind of food does your dog eat? (brand)*
Please note training goals for your dog during their course with us*
ex. leash walking, greetings, reactivity, etc.
How much food does your dog eat? (standard 8 oz measuring cup)
Do they...*

Eat it all at onceNibble throughout the daySkip mealsRequire canned food (or something similar) to make it more palatable
Does your dog have any know health problems/concerns? allergies, displaysia, etc.*
Veterinary Address and Phone Number
This section is for payment options only. IF you choose to pay here, you can select the options below. Or arrange payment with staff.
prevnext( X )
Deposit for Class Reservation$250.00

course length

Day Training $1,300.00

Course

Board and Train$2,000.00

Course

Hybrid $1,500.00

Course

Total $0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty: