Name of Dog Owner (s):

Home Phone:

Work Phone:

Cell Phone:

Address:

Postal Code:

E mail:

Emergency Name & Number
(other than yourself):

Do you have any physical limitations
which may affect your ability
to participate in class?

How did you hear about Clever Canines? Referral Word of Mouth Unleashed Dawg Tired Internet Search Clever Canines Web site Yellow Pages Phone Book(other than yellow pages) Brochure Veterinarian Other

If “Referred”, name of person or company:

If “Other”, please list how you heard of us:

Would you like to receive future information on upcoming events, activities, seminars, newsletters, reports, and/or updates: Yes No

Questions, Comments, Concerns:

Name of Dog:

Breed:

Birth date:

Current age:

Weight (in lbs):

Gender: Male Female

Spayed or Neutered: Yes No

Licensed: Yes No

Where did you get your dog? Breeder Arf Friend/Family Member Pet store Rescue society Humane society City pound Newspaper Other

If “Breeder”, what is the name and city of breeder:

If “Other” please explain:

Why did you choose this specific dog and / or breed?:

Name of Veterinarian:

Date of last vaccinations:

What kind of food does your dog eat? What Brand?

Any Health problems, Illnesses, Allergies, Limitations:

Have you ever participated in sheep herding in the past? Yes No

Has your dog ever participated in sheep herding in the past? Yes No

If Yes, name of clinic and or shepherd, where, when, and how often

Have you done obedience training with your dog before? Yes No

If Yes, give brief description of type of training & outcome

Current behavioral / training issues & challenges:

What outcomes do you want to achieve from herding: