EmailMe Form - Diabetic Alert Dog Registration Form

Diabetic's Name *

First Last

Parent Name(s)

First Last

Parent Name(s)

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Main Phone *

### - ### - ####

Secondary Phone

### - ### - ####

Email *

Workshop Attendence *

Student without dog ($100)

Student with dog ($200)

Second family member all day ($50)

Morning Intro Presentation Only ($50)

Individual Training with Scott on Friday

How many would like Saturday Optional Lunch, $10/person. *

Referred to Workshop: *

Information for those participating with Dog:

Please provide as much information as possible. If you are NOT bringing a dog, SKIP to the bottom of the form signature line.

Dog's Name

Breed(s)

Current Age

Date You Acquired Dog

MM / DD / YYYY

Sex

Male

Female

Veterinarian's Name/Clinic

Vet's Phone

### - ### - ####

Fixed?

Yes

No

Where did you get your dog?

My Diabetic Alert Dog:

My DAD was bred, raised and trained to be a DAD

I originally owned my dog and then trained to be DAD

I adopted my dog in order to train as a DAD

Vaccinations Current?

Yes

No

List the health history of your dog

ex: health issue 1, health isue 2,...

Is your dog on any medication?

Yes

No

If Yes, what medication and why?

Type of Collar and Leash used

Dog's diet

Dog's daily routine

List Training your DAD has had:

Show signs of aggression?

Yes

No

If Yes, Describe

Show signs of fears?

Yes

No

If Yes, describe

Where is your dog kept when you are home?

Where is your dog kept when you are away?

Where is your dog kept at night?

Check all items that your dog reacts unfavorably to

What things upset your dog?

How is your dog while in the car?

How does your dog react to being left alone?

What type of exercise does your dog get?

How would you describe your dogs personality?

What bad habits does your dog have?

What other bad behaviors does your dog do?

What commands does your dog respond to?

List other Commands you dog knows:

Who does your dog play with the MOST?

What does your dog prefer to do when you are at home?

Follow people around and nicely interact

Follow people around and obnoxiously interact

Be in the same area, but not much interaction

Independent and not follow people around

Interact with other pets

What games does your dog like to play?

How often does your dog come when called?

90% or more

75%

50%

25% or less

How much improvement would you like to see in your dog?

90% or more

75%

50%

25% or less

What would you specifically like to improve with your DAD?

ELECTRONIC
SIGNATURE & AGREEMENT TO TERMS CONDITIONS & POLICIES

I agree to the terms, conditions and class policies of Canine University *

I agree

Date *

MM / DD / YYYY

Information for those participating with Dog:

ELECTRONIC SIGNATURE & AGREEMENT TO TERMS CONDITIONS & POLICIES

ELECTRONIC
SIGNATURE & AGREEMENT TO TERMS CONDITIONS & POLICIES