| Instructors Course Start Date: * |
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| Participants Name: * |
Enter Name:
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| If seeking CEUS please enter CPDT # CCBC #: |
CPDT / CCBC #s |
| E-Mail Address: * |
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| Address (Street, Town, State & Zip): * |
Enter Address:
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| Dog's Name: * |
Dog's Name:
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| Dog's Age: * |
Dog's Age: |
| Breed: * |
Breed:
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Aggression:
(My dog has no known history of aggression) * |
My dog has no known history of agression. (Agree)
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Health Agreement
(My dog is in good physical condition and free of contagous illness and parasites): * |
Health Agreement
(Agree)
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Immunization Agreement
( My dog is current with Rabies and Distemper immunizations) If using an alternative immunization program please contact Sumac): * |
Immunization Agreement
(Agree):
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| How did you hear about this course?: * |
How did you hear about this course? |
Release:
(I understand the training dogs is not without risk. I agree to release and forever discharge Sumac, Wag It Inc emplyees, associates, guests, and class participants from any and all injury (incuding dog bite) dammageor loss) * |
Release
(Agree)
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Payment Options:
(registration will be held for 7 days if payment will be mailed) * |
(CC * Pay Pal * check)
Do not enter credit card number here. |
You will automatically be redirected to our shopping cart to submit your payment after completing this form.
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