Dirty Tails



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Registration & Release

Owners Information:

Name(s):

Address:

City, State, Zip:

Email Address:

Cell Phone:

Business Telephone:

Home Telephone:

How did you hear about us?

Emergency Contact Name & Phone: ____________________________________________________

Person(s) authorized to pick-up your dog: ___

___________________________________________________________________________________

Dog’s Information:

Name:

Breed (if mix, best guess):

Color(s):

Sex:

Birthday (month/year):

Weight:

Veterinarian Information:

Name:

Telephone:

City/State:

Please attach veterinary records/vaccination history.

*FLEA COLLARS ARE NOT PERMITTED IN DAYCARE. We reserve the right to refuse any dog for carrying fleas, please check your dog prior to arrival.

Do you give Dirty Tails permission to speak with your vet? [ ] Yes [ ] No INITIAL_______

Any current Medications: ___________________________________________________________

Please list any medical conditions and/or health concerns:

Pets’ Medical & Personal History

Is your dog fixed? Yes / No (All dogs over 7 months must be spayed/neutered)

Dogs behavior with people: [ ] Fearful [ ] Aggressive [ ] Dominant [ ] Submissive [ ] Playful

Dogs behavior with dogs: [ ] Fearful [ ] Aggressive [ ] Dominant [ ] Submissive [ ] Playful

Is your dog good with children? Yes / No / Not Sure Are there children in the home? Yes / No

Is your dog good with cats? Yes / No / Not Sure Are there cats in the home? Yes / No

Are there any other dogs in the home? Yes / No ______________________________________

Has your dog ever bitten another dog/human? Yes / No ________________________________

________ _________________ _____

Has your dog ever participated in daycare before? Yes / No If yes, where?________________

________ ____________

Has your dog ever participated in training before? Yes / No If yes, where? Do you have specific command words? : ________ _____________ ______

Is your dog on a monthly flea & tick treatment? Yes / No If so, what brand? _______________

Has your pet ever tested positive for Giardia? Yes / No If yes, when? _____________________

Do you take your pet to Dog Parks? Yes / No AND is your pet a poop eater? Yes / No

Is your dog crated at home? Yes / No When? ________________________________________

Has your pet ever experienced any of the following? : If yes, please detail

[ ] Food Allergies_______________________________________________________________

[ ] Bloat_______________________________________________________________________

[ ] ACL Injury__________________________________________________________________

[ ] Seasonal Allergies____________________________________________________________

[ ] Bee Stings/Allergies___________________________________________________________

[ ] Vaccine Reactions____________________________________________________________

[ ] Intestinal Parasites____________________________________________________________

[ ] Skin Conditions______________________________________________________________

[ ] Allergies to any shampoo or colognes____________________________________________

[ ] Collapsed Trachea____________________________________________________________

[ ] Dog Attacks_________________________________________________________________

[ ] Allergic Reaction to medication, including flea & tick product_________________________

*In the event of allergic reaction do you give Dirty Tails permission to give your pet

Benadryl? Yes / No INITIAL_______

[ ] Severe Reaction to Fleas_______________________________________________________

[ ] Ear Infections_______________________________________________________________

[ ] Eye Infections, Inc Pink Eye____________________________________________________

[ ] Diagnosed with Kennel Cough/Flu/Upper Respiratory Infection________________________

[ ] Seizures____________________________________________________________________

[ ] Warts______________________________________________________________________

[ ] Anxiety Issues (i.e. Thunder & Lighting, Men, Separation, crates?)_____________________

[ ] Toy or Food Aggression_______________________________________________________

Terms & Conditions

1. Owner certifies the accuracy of all information Owner has conveyed about Owner’s pet to Dirty Tails.

2. Owner represents that all information that Owner has given to Dirty Tails about Owner is accurate.

3. Owner agrees that if Owner’s pet becomes ill or seems to be in need of medical consideration, Dirty Tails, at its sole discretion, reserves the right to administer aid and/or to engage the services of a veterinarian and the expenses thereof shall be paid by the owner. Owner gives consent to Dirty Tails to act on the Owners behalf in obtaining emergency veterinary care at the Owners expense if deemed necessary by Dirty Tails. Owner agrees to indemnify and holds Dirty Tails and its employees harmless from said expenses.

4. Owner understands that any problem, including but not limited to injury, illness or death that occurs while on our premises, all dog(s) will be treated as deemed best by the staff of Dirty Tails, in their sole discretion, and that I assume full financial responsibility for any and all expenses involved.

5. Owner agrees that their dog is in good general health. Owner will provide valid proof that he/she is current on Rabies, DHLPP, Bordatella, negative fecal exams (must include giardia). Vaccinations/tests will be provided before she/he can stay at Dirty Tails. In addition, owner agrees that their dog is on a scheduled flea/tick prevention program. Flea collars are not permitted for daycare.

6. Dirty Tails has the right to videotape, photograph, and/or record your dog during their time at Dirty Tails and to post and/or reproduce any and all photographs taken without limitation to Dirty Tails’ website, promotional materials and merchandise, without becoming liable to the Owners dog for any royalty payment of any kind.

i. Opt Out

7. Owner agrees that should their dog exhibit inappropriate aggressive behavior toward other dogs or employees, for the safety of all the concerned he or she will be separated from the play area until pick up.

8. In the event a dog is abandoned at Dirty Tails, due diligence will be undertaken to locate the owner. If the owner cannot be located, animal control shall be contacted.

9. Due to the safety of all pets and people; Power breeds are not permitted for daycare. (This is only for the protection of other animals. We groom ALL breeds and understand these breeds are sweet, gentle, loyal and loving pets, however, some can be prone to aggressive behaviors in pack environments.) Thank you for your understanding.

10. Dirty Tails reserves the right to refuse any dog, for any reason, at any time.

11. Dirty Tails shall exercise reasonable care for Owners dog while in Dirty Tails custody. Owner recognizes the potential risks involved group play/dog daycare, and grooming due to the unpredictable nature of dogs.

12. Owner further agrees that the pet shall not leave this facility until all charges due are paid by Owner or proper payment arrangements are agreed upon by both parties. Upon late pick up, $1 per minute will be charged.

13. Any claim or controversy arising out of or relating to this contract, or the breach thereof, or as the result of any claim or controversy involving the alleged negligence by any party to this contract, shall be settled by arbitration in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by an arbitrator my be entered in any court having jurisdiction thereof. The arbitrator shall, as part of his/her award, determine an award to the prevailing party of the costs of such arbitration and reasonable attorney fees of the prevailing party.

14. This contract contains the entire agreement between parties. All terms and conditions of this contract shall be binding on the heirs, administrators, personal representatives and assigns of the Owner and Dirty Tails.

15. All belongings are to be labeled and able to be laundered on site as needed. Your pets’ personal belongings may be left on property. However, Dirty Tails is not to be held liable for lost/stolen or discarded goods.

16. Owner gives Dirty Tails, LLC authorization to access pets’ medical records.

17. Owner agrees pet will refrain from daycare, if he or she is experiencing any diarrhea, coughing, vomiting or excessive itching. Pet must remain symptom free for 72 hours.

18. Owner agrees to late pick up charges of $10 per 15 minutes after closing time. After 1 hour pet will be admitted into overnight boarding until the following day at the owner’s expense.

By signing on the line, you agree to the terms and conditions above:

X

Signature (Owner) Today’s Date

6/18

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