DOG’S DAY OUT



dog’s day out APPLICATION

DATE:_______ REFERRED BY:__________________

I. GENERAL INFORMATION

OWNER’S INFORMATION: (please print)

________________________________________________________________________

Name

________________________________________________________________________

Address

________________________________________________________________________

___________________________ __________________________________________

Home Phone Employer Name & Phone

___________________________

E-mail

EMERGENCY CONTACT

_______________________________ ___________________________________

Name / Relationship Phone

VETERINARIAN

_______________________________ ____________________________________

Name Phone

________________________________________________________________________

Address

DOG INFORMATION

_______________________________ __________________

Name Age / D.O.B.

_______________________________ ___________ _________________

Breed Weight Sex/Altered Y/N

If not altered yet, is date set for surgery?_________________________________

HEALTH AND TEMPERMENT

CERTIFICATION AND AGREEMENT

I, ______________________________________________, hereby certify that my dog(s)

Name (s): ____________________________________

is/are in good health and have not been ill with a communicable disease in the last 30 days.

I further certify that my dog(s) have not harmed or shown aggressive or threatening behavior towards any person or any other dog.

Vaccinations given (as deemed necessary for your dog by your veterinarian):

DHPP expiration: __________________

Bordatella expiration: __________________

Rabies expiration: __________________

Other: __________________

Titer Testing: __________________

I understand that I am solely responsible for any harm or illness caused by my dog(s) while my dog(s) is/are attending Dog’s Day Out.

I further understand and agree that Dog’s Day Out and their staff will not be liable for any problems that develop provided reasonable care and precautions are followed, and I hereby release them of any liability of any kind whatsoever arising from my dog(s) attendance and participation at the facility.

I agree to notify Dog’s Day Out if my dog(s) has a communicable illness and will keep him/her at home if I am aware of symptoms.

I further understand and agree that any problem that develops with my dog(s) will be treated as deemed best by the staff of Dog’s Day Out and that I assume full financial responsibility for any and all expenses involved.

Dog’s Day Out reserves the right to refuse or terminate admittance of any dog, at any time, deemed unsuitable for this environment.

I certify that I have read and understand the rules and regulations set forth on the preceding page and that I have read and understand this agreement. I agree to abide by the rules and regulations and accept all the terms, conditions, and statements of this agreement.

Seattle, WA

Dated: _____________ Signature of Owner_______________________________

III. RATES

APPLICATION/EVALUATION (one-time) FEE: $20.00

DAY CARE:

1-2 day per week $38.00/day

3 + days/week $35.00/day

Discounted daily rate only for dogs with 3+ regular days, not floating or occasional spaces.

BATH: $30 - $50 (depends on size/coat)

TOENAIL TRIM: $15.00

RATE AGREEMENT (READ CAREFULLY!):

*Payment is due day of service.

*Client is responsible for payment unless 24 hour notification of absence from day care is given.

*If discounted rate (3 or more days/wk) desired, payment is due at the beginning of week.

*Day substitution on available basis.

*Late pick-up fee: $25 for every 15 minutes (or part thereof) past 6:30 PM. $1/minute past the first 15 minutes.

*If your dog will be out of day care for more than 1 week you are required to pay for his day(s) or forfeit your regular day care space.

I understand and agree to the above rates and terms of payment.

Signature of owner

IV. HISTORY

1. How long have you had your dog?

2. Where did you get your dog? If your dog was adopted, do you have any knowledge of past history?

3. How many people live in your household?

Adults:

Children: (sex & ages):

4. Are there other animals in your household? ____yes ____no

If yes, list other animals by species, breed, age, sex, intact/altered:

5. How does your dog get along with the other resident animals? (ignore, chase, play, sleep with, groom, fear?)

6. Has your dog previously spent a lot of time home alone? How long? Was he indoors or outdoors? Was he confined?

7. Is he ever destructive? When left alone? To what -- pillows, books, digging...?

8. Is your dog housebroken? How many hours can he go without an accident?

9. Is he crate trained? Does he spend any time in a crate now? When?

V. BEHAVIOR

1. Is your dog used to being around other dogs? Who are the dogs – yours, neighbor’s, friend’s?

Do you use the city off-leash parks? ____yes ____no

How does your dog react to other dogs? Ignore, play with?

Does your dog seem to like certain kinds of dogs (males, females, big, small, certain breeds…?)

What kind of games does your dog play with other dogs?

Does your dog ever have any trouble with any dogs (males, females, scuffles over toys or food?)

How does your dog react to a new dog approaching him on leash and off leash?

2. Has your dog taken any group classes or private training?

3. If yes, when and where (facility and/or trainer’s name)?

4. What cues does your dog know?

5. What kind of collar and leash do you use to walk your dog?

6. Does your dog play with any toys? ____yes ____no

If yes, what kinds of toys does he like and what kinds of games does he play with them?

7. Has your dog ever shared his toys or food with other animals?

8. Has your dog ever growled or snapped at anyone who’s taken his food or toys away from him? Human? Animal?

9. Are there any kinds of people your dog automatically fears or dislikes?

10. Are there any kinds of dogs your dog automatically fears or dislikes?

11. Has your dog been around puppies? How does your dog react to puppies?

12. How often is your dog walked outside?

13. Has your dog ever growled at someone? ____yes ____no

Who? What were the circumstances?

14. Has your dog ever bitten someone? ____yes ____no

Who? What were the circumstances?

15. Has your dog ever jumped a fence? ____yes ____no

How high? Fence material:

16. Does your dog have any problems with any of the following (circle):

Mouthiness

Jumping up

Housetraining

Barking

Digging

Ignoring cues

17. Is your dog frightened of any noises?

VI. HEALTH / GROOMING

1. Does your dog have any food allergies or on a special diet?

2. Does your dog have any medical conditions or surgical history?

3. Is your dog currently on any medication or supplement? What kind? Dosage?

4. How does your dog react to having his nails clipped? Do you do it yourself?

5. Does your dog have any sensitive spots on his body?

6. Any other comments about your dog’s behavior that may be helpful?

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