Doggie Day Care Agreement and Profile The Dog House 12704 Foust Road Conneaut Lake, PA 16316 (814)382-2267 Date In: Time In: By (Staff): Date Out: Time Out: By (Staff): Owner Name: Address: City: State: Zip: Home phone: 2 nd Home phone: Work phone: 2 nd Work phone: Cell phone: 2 nd Cell phone: E Mail: 2nd E Mail: Others authorized to pick up dog (Photo ID Required) Primary Phone # Alternate Phone # Emergency Contact (non owner) Primary Phone # Alternate Phone # Pet s Name: Breed: Age: M F DOB: Weight: Spayed* Neutered Licensed? Y N # Microchip? Y N # * Please note females in season are prohibited from participating in day care activities Veterinarian: Phone: Method of Payment: Cash Check Credit Card (Master Card, VISA, Discover) Updated: 11 12 13 Page 1
Policies and Disclaimer: Owner acknowledges receipt and acceptance of the Operating Policies of The Dog House Owner certifies that their dog does not violate the Breed Restrictions policy of The Dog House. Owner has provided a copy of their pets current veterinary records or completed a Conneaut Lake Bark Park Health Agreement form. Owner will also disclose any allergies or medical conditions such as seizures, luxating patella, hip dysplasia, ACL issues or other conditions which are necessary to aid staff in providing a safe environment for their dog. I hereby waive and release C. L. Bark Park Company, Conneaut Lake Bark Park Inc., and Forever Friends Pet Memorial Park, Inc., its employees, owners and agents from any and all liability of any kind, for injury or damage which my dog, myself, members of my family or guest may suffer, however caused, including specifically but not without limitation, any injury or damage while using the entire Bark Park Complex or its services, or while attending any training session or other event function of C.L. Bark Park Company, Conneaut Lake Bark Park, Inc., and Forever Friends Pet Memorial Park. I have had sufficient opportunity to read this and fully understand this entire document and agree to be legally bound by its terms. Signature Print Name Date Updated: 11 12 13 Page 2
Meet My Dog Day Care Profile Date Dog s Name Health: How I routinely care for my dog Dog food brand/type: Dry Canned Raw Homemade Grooming? Yes No How often? Nail Yes No How often? trimming? Allergies? Yes No If yes, please list: Past injuries? Yes No If yes, please list: Other issues? Yes No If yes, please list: Medication? Yes No Type, amount and frequency: Environment: What my dog s home life is like Other pets? Yes No If yes, please list: Other people? Yes No If yes, please list: Updated: 11 12 13 Page 3
Regular exercise? Yes No If yes, please describe: Obedience training? Yes No If yes, with who and where? Play group? Yes No If yes, where/how was the experience? Day care? Yes No If yes, where/how was the experience? Dog park? Yes No If yes, where/how was the experience? Kennel? Yes No If yes, where/how was the experience? Favorite playmates (m/f, breed, size): Socializes with other dogs outside of home? Daily Weekly Monthly Occasionally Rarely Never Temperament: How my dog interacts with others My dog s personality: Reaction to new dogs? Reaction at the vet? No touch areas? Stressful places, objects, situations? Ever bitten or harmed a person or dog? If yes, please describe: Bad dog behaviors: Barking Biting Digging Eating feces Eating objects Escaping Food aggression Leash aggression Marking Updated: 11 12 13 Page 4
Mounting Small/large dog aggression Over protective Toy aggression Separation anxiety History: My dog s background Length of ownership? How acquired: Breeder Who: Rescue Where: Other Describe: Knowledge of history? Why have you chosen Day Care for your dog? Is there anything else that we need to know about your dog? How did you hear about The Dog House @ Conneaut Lake Bark Park? By signing this form you acknowledge that all information is true to your knowledge. Signature Date Print Name Updated: 11 12 13 Page 5
Conneaut Lake Bark Park, Inc. 12810 Foust Road Conneaut Lake, PA 16316 814-382-2267 / 814-382-2478 WWW.CONNEAUTLAKEBARKPARK.COM 2013 HEALTH AGREEMENT FORM Owner s Last Name Pet s Name Pet ID: License, Microchip Bark Park clients use veterinarians from different clinics, counties and states. We ask that a veterinarian note the due date for each test or vaccination we require or recommend for membership as indicated below: REQUIRED TESTS DATE DUE RECOMMENDED VACCINES DATE DUE ANNUAL FECAL EXAM Lyme Canine Influenza REQUIRED VACCINES DATE DUE OTHER DATE DUE Rabies Parvovirus Canine Distemper Leptospirosis Canine Adenovirus Bordatella VETERINARIAN S ACKNOWLEDGEMENT: I, have recommended the pet named above receive the vaccinations and tests indicated. Veterinarian Signature DATE: Veterinarian Office PET OWNER S AGREEMENT: I, agree to the above requirements and will monitor the wellness of my pet. I agree not to bring my pet to the Bark Park if there are signs of illness (coughing, vomiting, diarrhea or lethargy). Owner Signature DATE: Updated: 11 12 13 Page 6