Beaver County Kennel Club

Handler’s Name:________________________
Dog’s Name:___________________________
Breed:_________________________________
Dog’s Sex:_____________________________
Dog’s Age:_____________________________


Your dog must be immunized against the diseases listed below.
Please fill in the date of immunization.
Parvo ____________
Leptospirosis ___________
Distemper ____________
Rabies ___________
Hepatitis ____________

Is there any particular information (physical, medical, behavioral) concerning
your dog that you think we should know? Explain:
_________________________________________________________
_______________________________________________________________________________

How did you find out about our obedience classes?

Check one

Classified Ad in Newspaper
Flier at Vet’s Office
Referred by a friend
Other, explain_________________________

I hereby certify that I will indemnify and hold harmless the Beaver County Kennel Club, Inc., and all persons connected therewith in any capacity whatsoever from any and all liability, cost, and expense for injury or damage to persons or property caused by any dog brought by me to any training class or other event held or sponsored by the Beaver County Kennel Club, Inc. That I release the club and all persons connected therewith in any capacity whatsoever from any and all liability for any injury or damage to my person or property sustained at the training classes or any other event held or sponsored by the club, and that I assume the risk of such injury or damage. I understand that my dog may be dismissed from class should he/she prove a threat to any person or dog on the club’s premises. Dismissal is at the discretion of the instructors.
Signature:_________________________________Date:____________
Address:___________________________________________________
Phone: (home)_________________ (work)_______________________