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SERVICE DOG SEMINARS Registration Form 2018
Service Dog & D.A.D. Seminars
Attendee Name
*
First
Last
Service Dog Interest
Diabetes or GSD
Post Traumatic Stress Disorder
Emotional Support
Medical or Psych Professional
Business Owner
Other
Parent Name(s) (If Attendee is a minor)
First
Last
Parent Name(s) (If Attendee is a minor)
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Main Phone
*
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Secondary Phone
###
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Email
*
Referred to Workshop:
*
Workshop Attendance (check all that apply)
*
Service Dog Seminar
Diabetic Alert Dog Seminar
Second family member ($50/day)
Third family member ($50/day)
Private Training Appt
Public Access Training Day
Airport Training Day
Check all that apply
Saturday Dinner
0
1
2
3
4
5
Need Lodging?
*
Yes
No
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
###
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###
-
####
Spayed/Neutered?
Yes
No
Where did you get your dog?
My Service Dog (SD):
My SD was bred, raised and trained to be a SD
My SD was selected by a Rescue Organization
I originally owned my dog and then trained to be SD
I adopted my dog in order to train as a SD
Vaccinations Current (please supply copy of current record before workshop)?
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
Do you have other pets/livestock at home? Details
Dog's daily routine
List training your SD has had:
Shows 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?
In house loose
In house crated
In separate area of house via gate or door
Outdoor Invisible Fence
Outdoor fencing
Outdoor dog kennel
Where is your dog kept when you are away?
In house loose
In house crated
In separate area of house via gate or door
Outdoor Invisible Fence
Outdoor fencing
Outdoor dog kennel
Where is your dog kept at night?
In house loose
In house crated
In separate area of house via gate or door
Outdoor Invisible Fence
Outdoor fencing
Outdoor dog kennel
Check all items that your dog reacts unfavorably to
Men
Women
Cars
Stangers
Cats
Kids
Trucks
Other Dogs
Loud Noises
Dog is fine with all above
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?
Shy
Friendly
Fearful
Confident
Quiet
Indifferent
Independant
Agressive
Passive
Nervous
Calm
Loud
Curious
Bored
High Energy
Laid Back
Dominant
Submissive
Playful
Dependant
*Check all that apply
What bad habits does your dog have?
Barks or Howls
Digs
Chews
Bites
Eats stool
Steals
Runs away
Jumps up
Gets in trash
Not housebroken
No bad habits
What other bad behaviors does your dog have?
What commands does your dog respond to?
Come
Sit
Down
Heel
No
Leave it
Back
Stand
Back Up
Wait
O.K.
Drop/Give
Let's Go
Under
None
List other commands your dog knows:
Who does your dog play with the MOST?
Service client
Adults
Children
Other animals
Him/Herself
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
Be independent and not follow people around
Interact with other pets
What games does your dog like to play?
Fetch/Retrieving
Hide & Seek
Chase
Tug-o-War
Scent Games
*Check all that apply
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 SD?
ELECTRONIC SIGNATURE & AGREEMENT TO TERMS CONDITIONS & POLICIES
I agree to the terms, conditions and policies of Canine University of Ohio, Alert Canine Training, Geauga Rescue Village and Scott Smith.
*
I agree
Date
*
MM
/
DD
/
YYYY
