Canine Kindergarten Inc.

Application Type           ( Select Application Type to Highlight Required Fields )

          Daycare/Sleepovers     Puppy Playgroup     Training     Grooming

Location

          Verplanck     Mt. Kisco

Owner Information

First Name:        Last Name:
Address:
City:                   State:     Zip:
Home Phone:       Work Phone:        Cell Phone:
Email:

How did you hear about us?

Emergency Contact Information (Other than self)

Spouse/Significant Other

First Name:              Last Name:
Phone:

Someone Outside Immediate Family

First Name:              Last Name:
Phone:                                Relationship:

Veterinarian Information

Hospital:            Doctor's Name:
Address:
City:                   State:     Zip:
Phone:

Dog Information

Name:            Primary Breed:        Color:

Sex:    Male Female             Neutered/Spayed:     Yes No

Birth Date:        Weight: lbs.

Other Household Pets

Species	Sex	Neutered	Age
	Male Female	Yes No
	Male Female	Yes No
	Male Female	Yes No

Medical History

Date of latest vaccination against (please provide copy from veterinarian)

Rabies:
DHLPP:
Bordetella:
Fecal Exam:

Type/Frequency of Flea/Tick preventive:

Please list any past or current medical
problems and treatments:

Behavior

Has your dog ever ...

Been to obedience class?	Yes No Do not know
Been socialized to other dogs?	Yes No Do not know
Had to share food/water/toys with other dogs?	Yes No Do not know
Growled at a person?	Yes No Do not know
Growled at another dog?	Yes No Do not know
Bitten a person?	Yes No Do not know
Bitten another dog?	Yes No Do not know

Other Information

What do you hope to achieve for you and your dog by
utilizing our services?

Is there anything else you would like to share
with us about your dog?