Minnesota Valley Humane Society 1313 Highway 13 East, Burnsville, MN 55337 952-894-5000 www.MVHSpets.org Class Information First Class Choice Class: ____________________ Start Date: ___________ Time: ________ Alternate Choice Class: ____________________ Start Date: ___________ Time: ________ Owner's Information Name: ________________________________ E-mail Address: (optional) _____________________ Address: ________________________________________________________________________________ City/State/Zip: ____________________________________________________________________________ Contact Phone Number and best time to call: ___________________________________________________ Please describe any physical conditions or restrictions you have that might interfere with training or in any way limit your participation in this class. (optional) __________________________________________________________________ _____________________________________________________________________________ Dog's Information Dog's Name: ___________________________ Breed(s): ________________________________ Dog's date of birth or current age: ________________ Sex: M F Sterilized: Y N How long have you owned this dog? ___________________________________ Where did you obtain this dog? _______________________________________ Please describe any physical conditions this dog has that might interfere with training or in any way limit his/her participation in this class. _________________________________________________________________________ ___________________________________________________________________________ Dog's Habits Where is this dog kept when someone is home? __________________________________________________ Where is this dog kept when no one is home? ____________________________________________________ Has this dog ever bitten a person or another dog? Yes No If so, please describe how many times and the circumstances. ________________________________________________________________________ ________________________________________________________________________ Are there any other dogs in your family? If so, how many? __________________________________________ How does this dog react to: Men? __________ Women? ____________ Children? ______________ Strangers? ______________ Other dogs? ___________________ What bad habits does this dog have? (Check all that apply) Barks or howls __ Digs __ Chews __ Runs away __ Jumps up __ Gets in trash __ Chases things __ Bites __ Begs __ Dominates __ Submissive Urination __ Separation Anxiety __ Other ______________________________________________________________________________ What other training classes has this dog completed? When? Where? _____________________________________________________________________________ What would you like to accomplish in this class? ____________________________________________________________________________ How did you learn about our classes? _________________________________________________ Payment Information All payment is due in full with this application. Rebates for dogs adopted from Minnesota Valley Humane Society will not be issued until the dog has successfully completed the course. We are able to accept checks and credit cards. Cash payments must be made in person. The Complete Puppy $60 $ __________ Better Dog I $75 $ __________ Better Dog II $60 $ __________ Fun and Games $50 $ __________ Subtract $20 when registering for a series of any 3 courses - $ __________ Total $ __________ MasterCard/Visa/Discover # ____________________________ Expiration Date ___________________ Signature _________________________________________________________________________ Please complete and return this application, your signed "Waiver, Assumption of Risk and Hold Harmless Agreement", and check (Payable to Minnesota Valley Humane Society) or credit card number to: Canine U Minnesota Valley Humane Society 1313 Highway 13 East Burnsville, MN 55337 Or fax it to 952-894-6669, attention Emily. Registration in on a first come, first serve basis. If the class you desire is full, we will call to schedule you for the next available session. Please do not come to the first class until you have been confirmed. Please call 952-894-5000 with any questions. Please send a copy of your dog's current vaccination record along with this application. If you do not have a copy available, be sure to bring it to the first day of class. In order to keep all our class participants healthy, your dog will not be allowed in class until we have this. Veterinarians are welcome to fax records to 952-894-6669, attn: Emily. MVHS use only: Class: ________________________ Date: ______________________ Completed: Y N Class: ________________________ Date: ______________________ Completed: Y N Class: ________________________ Date: ______________________ Completed: Y N Waiver, Assumption of Risk and Hold Harmless Agreement I understand that attendance at a dog training class of any kind is not without risk to myself, members of my family or guests who may attend, or my dog, because some of the dogs to which I (we) may be exposed may be difficult to control and may be the cause of injury or illness even when handled with the greatest of care. I agree that I will abide by all safety rules and requests provided by the Minnesota Valley Humane Society's employees and representatives. I hereby waive and release the Minnesota Valley Humane Society, its directors, officers, employees, instructors, assistants, volunteers, and representatives from any and all claims, damages, loss, or liabilities of any nature, for injury or damage which I, my dog, or my guests may suffer in connection with my attendance or participation in training sessions or my presence at the Minnesota Valley Humane Society, including specifically, but not without limitation, any injury or damage resulting from the action of any dog. I expressly assume the risk of such damage or injury when attending any training sessions or other function, or while on the training grounds or the surrounding area thereto. As required in order for my application to be accepted for this training class, I hereby agree to indemnify and hold harmless the Minnesota Valley Humane Society, its directors, officers, employees, instructors, assistants, volunteers, and representatives from any and all claims, or claims by any member of my family or any other person accompanying me to any training session or function while on the grounds or the surrounding area thereto as a result of any action by any dog, including my own. I understand that if I wish to cancel, I must give notice to the Minnesota Valley Humane Society at least 24 hours prior to the first class meeting in order to receive a full refund. Any refunds after that time will be issued at the discretion of the Minnesota Valley Humane Society. I have read the above agreement carefully and fully understand this agreement. Signature of all who will be attending class, and by the parent or guardian of any child who will be attending. _____________________________________ ____________________ Signature Date For MVHS use only Staff Initials: ________________ Class Title: ____________________________ Class Dates: _______________________________ Date Application and Payment Received: _________________ Check # ______________ V/MC/DV Cash Rung into Register? Y N PLU# CP BI BII FG Application Received By: Mail In-person Fax Vaccination record received? Y N (Staff- Please make copy and staple to application) RP Entered? Y N Postcard sent? Y N Date: _______ Phone call reminder? Y N Date: __________