Name __________________________________ Email _____________________________

Home phone # _____________Work phone # ______________ Cell# _________________

Street Address ______________________________________________________________

City, State, Zip _____________________________________________________________

Occupation(s) ______________________________________________________________

Do you have a hearing problem or other physical limitations?_________________________

Dog’s name _______________________ Breed ____________________ Age ______ M / F

Vet ________________________ Health Problems_________________________________

Medications/Supplements________________________ Neutered yes / no

Age dog obtained_____From________________History_____________________________

Is the dog outdoors, indoors or both? Sleeps in or out Left alone daily for ______hours

Daily play w/ you_________w/ dogs_________ Time spent on walks___________________

Diet/food ____________Amount per day_______ free fed or scheduled mealtimes at ______

Current Training _____________________________________________________________

Type of collar and reward(s) used for training ______________________________________

List specific problems you are having ____________________________________________

___________________________________________________________________________

How do you deal with these problems? ___________________________________________

___________________________________________________________________________

Dog’s reaction?______________________________________________________________

What are your goals and expectations for your dog and this class?______________________

___________________________________________________________________________

Prior training and classes ______________________________________________________

___________________________________________________________________________

Name of the course you are requesting____________________________________________

Start date__________________ Location __________________________ Time__________

Amount of check______________ Referred by _____________________________________

Please complete this form. Return it with the signed waiver and a check made out to Cerena Zutis and mail it to 1773 Lake St., San Mateo, 94403 Thank you!