Clinic Registration Form

Your Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email*

example@example.com

Additional email (another family member or dog owner)

example@example.com

phonetextemailOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What clinic are you registering for?*

ie. Shock Free Rattlesnake Avoidance Clinic

If there are multiple dates or times offered for the clinic, please list the order of your preference. If there is a specific reason for one preference over another, you may add an explanation.

ie. Saturday morning session is preferred and Sunday morning is second choice. My dog is prone to overheating and afternoons are usually too hot.

Because each clinic is tailored to meet the group's needs, and needs can change depending on experience, location, and the individuals comprising the group, please answer each of the following questions.

What is the name of your dog that will be attending with you?*

Does your dog have any medical conditions or take any medications on a regular basis?*

Please list medical conditions and/or regular medications.

Have you ever taken a class with your dog before, or had private lessons with a trainer?*

Please list the trainer's name or organization if you have, or put "no".

Please give me a little information regarding your dog's breed or type (ie. Parson Russell Terrier/mixed/hound).*

Be as specific as you like!

Please share some information on how your dog came into your life (ie. adopted from shelter, bought from breeder, got from family member, etc.)*

You may state the name of breeder or shelter if you like.

What is the approximate age or date of birth for your dog?*

Tell me what goals you hope to accomplish with the class. Be as specific as you can, for instance, "I want to learn how to get my dog to come back to me reliably in high distraction areas such as a park with a lot of people or when we are hiking in the mountains. My dog likes to run to meet new people, or chase rabbits when we are doing these things."*

Briefly describe your dog's personality and if it changes, under which circumstances does that occur.*

ie. generally happy and calm in evening but energetic in morning or calm and happy at home but reactive to other dogs at the park/when in the vehicle/etc.

Briefly tell me how you think your dog feels about you!*

What are all of the wonderful and good things about your dog?*

You obviously love your dog or you wouldn't have taken the time to fill out this form or invest in a class, so brag a bit!

All payments must be paid in full prior to the close of registration unless other arrangements are made ahead of time.

Payments are non-refundable but may be transferred to another participant prior to the start of the class. Please speak to organizer if you are unable to attend. Alternate arrangements may be offered.

Payments can be made via the website, www.christichapman.org or Venmo or Paypal.

Clinic Terms:

Clinicians have overhead expenses that are factored into the clinic cost, and each clinician will have different policies. If you register and are unable to attend, please contact Christi Chapman to make alternate arrangements no later than 36 hours prior to the clinic.

Registration is only confirmed upon receipt of payment.

Submission of this form is not a guarantee of clinic reservation. Payment in full MUST be submitted to guarantee clinic reservation.

Please sign here to acknowledge that you have read and agree to the terms of the clinic registration.

Date*

Date

Enter the message as it's shown*

You are all done! Please hit the submit button and I will see you in class!