Foundation Class Application

Foundation Class Application
Date of Application*

MonthDayYear
Date
Hander's Information
Handler's Name Old
Handler's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address old
Best Tel.# to reach you*
Email*
example@example.com
NOTE: JCAC members receive discounted class fees and other discounts for some of our events. To join or to renew your membership in Jumping Chollas, go to our website for information and or click here to apply online.
Are you a club member?*

YesNo
NOTE: Jr. Handlers are required to have a Parent or Legal Guardian accompany them and stay with them for the duration of each class.
Is this for / are you a Jr. Handler (12 to 18 years of age)?

NoYes
Jr. Handler's age?*
Provide name of Parent / Legal Guardian.*
Parent's Email if different from above
example@example.com
Tel.# if different from above
Dog's Information

Dog Info*

	Dog
Call Name
Breed
Age
Gender (M or F)
Intact or Neutered - specify
Jump Height 4,8,12,16,20 Not sure

What's your dog's training level / background?*

ObedienceConformationHouse dog / petNone
My dog will reliably (tick all the apply):*

ComeSitDownStandStay on commandAll of the above commandsNone of the above commands
How is your dog with people / strangers?*

FriendlyReservedShyMay biteWill bite
How's your dog with other dogs - on or off leash?*

Very friendlyFriendly but reservedAggressiveOther
Vaccinations and/or health prevention (tick all that that apply):*

DHLLP vaccinationRabies vaccinationKennel cough / influenzaHeartwormAll of the above health checksNone of the above health checks
Additional Information / Comments / Questions
Waivers and Agreements
Statement of Responsibility & Waiver of Liability

I understand that:
- agility training is an activity that is held in the presence of other dogs and their owners/handlers
- the participation of my dog and myself in the agility training will require some physical activity on my part and on the part of my dog
- this activity will involve running among obstacles on my part, and running, jumping, and the use of obstacles such as tunnels, scaling planks and walls, teeter totters, jumps, tires, and other obstacles which could result in injury to me, to my dog, or to others.
I agree, represent, and warrant that:
1. I am in good health and can perform the physical activities necessary.
2. My dog is in good health and can perform the physical activities necessary.
3. My dog and I are both in physical condition to participate in the sport of dog agility.
4. My dog is friendly and not a hazard to persons or other dogs. I agree to take any steps requested by my instructor, the class coordinator or the training director if they feel that my dog is a hazard to persons or other dogs.
5. I agree to keep my dog under control at all times, to carefully watch him at all times when he is not confined to a crate or other similar device, and not to allow him to interfere with the participation of others in classes and other club activities.
6. I and my dog are participating at my own risk, and that Jumping Chollas Agility Club cannot in any way assume any responsibility for the health or safety or myself or my dog(s).
7. I will not hold Jumping Chollas Agility Club, its Board of Directors and officers, the Owner(s) of the training sites, the agility instruction staff, or any other persons or entities associated with Jumping Chollas Agility Club liable for any loss, injury, illness, expense or other incident or hardship that may arise in connection with my participation and/or my dog’s participation in the activity.
8. I further agree to assume full responsibility and liability for any and all injury or damage caused in any way by my dog(s) or myself. That I further agree to reimburse any person for any damage that I or my dog does or cause to another person, dog, equipment, or personal or business property.
9. I understand that, as a student or instructor training with Jumping Chollas, I have an obligation to help with equipment. In particular, if I attend the first class of the morning or evening, I must arrive at the designated time and help set up the equipment. I must help change jump heights during class. If I come to the late class, I must stay after class and help put the equipment away.
I have read the Statement of Responsibility and Waiver of Liability above and agree to uphold it.*

Yes
Collection and Use of Personal Information

The Jumping Chollas Agility Club Inc. [JCAC] collects personal data including name, address, telephone and email information and where appropriate, birthdate for minors, from this application for the purpose of club business related to classes. The JCAC does not and will not share, publish, sell, or distribute personal information to/with other organizations without the written consent of its members and clients.
I have read and agree with the collection and use of my personal information for the purposes outlined above.*

Yes
Electronic Signature Agreement

By selecting the "I agree and accept" button below, you are signing this Application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Application.
I agree that I am signing electronically.*

Yes
Check Payments Only
The training director will contact you when there is a slot available in the Foundation class and only then will your check be cashed. Until that time, your check will be held.

Mail your check out to JCAC and mail along with any Jumping Bucks to:

JCAC Training Director
3641 W. Aire Libre Ave., Phoenix, AZ 85053

Fee Category & # of Dogs*

	Select One
Non-Member @ $95
JCAC Member @ $85
Jr. Handler @ $45

You owe
Should be Empty:

Foundation Class Application

Hander's Information

Dog's Information

Waivers and Agreements

Check Payments Only