Gangway, Inc. Training Facility
42 Loshes Run Road Duncannon PA 17020
Phone: 717-834-9167
Fax: 717-834-5581
Email: gangway@pa.net
Application for Training
Name of Handler ______________________________________________________
Age(if under 18)_________
Address _____________________________________________________________
City _______________________________________ State ____ Zip ____________
Home Phone ______________
Email Address _____________________________________ Work Phone ______________
Owner’s Name ______________________________________________________________________
Dog’s Registered Name ___________________________________________________________________
How did you learn about our training?________________________________________________________
Dog’s Call Name _________________________________________________________________________
Breed ___________________________DOB____________ Sex – M F
How long have you had this dog? _______________________________
Is the dog Spayed or Neutered? Yes No
Have you ever owned a dog before? Yes No
Does you dog walk on a leash? Yes No
Has your dog shown any Signs of viciousness? Yes No If yes toward whom? People Dogs
Have you ever trained a dog before? Yes No
If Yes Where _____________________ Year trained ________
Have you ever shown in confirmation before? Yes No Any Championship titles? How many?________
Does your dog or do you have any physical limitations the instructor should be aware of? Yes No
If Yes, please explain
_________________________________________________________________________________________
Does your dog have any behavior problems the instructor should be aware of ? Yes No
If Yes, please explain
_________________________________________________________________________________________
Does your dog have any food restriction? Yes No
If Yes, please explain
________________________________________________________________________________________
Classes Interested in (circle one) Each Session is 7 weeks At $75.00/session
PUPPY, CANINE GOOD CITIZEN, BREED HANDLING, AGILITY
OBEDIENCE: Pet - Level I, Level II, Competition - Beginning Basic, Advanced Basic, Novice, Open, Utility
TIMES INTERESTED (indicate with 1ST & 2ND)
Cannot guarantee due to participation & first come/first serve)
MONDAY TUESDAY WEDNESDAY THURSDAY
6:15 ____ 6:15 ____ 6:15 ____ 6:15 ____
7:30 ____ 7:30 ____ 7:30 ____ 7:30 ____
Vaccination Records (Documentation Required – bring to first night of class)
Rabies _________________ DHLP ________________ Parvo _______________
Veterinarian ____________________________
Amount paid Date Paid___________ Cash __________ Check # _____________
(make checks payable to Darlene Johnson)
Your commitment is required. Payment is required prior to classes starting to reserve the time requested. Refunds will be made only 1 week prior to the class starting, as you may be preventing another from attending the class.
AGREEMENT TO HOLD HARMLESS, WAIVER AND ASSUMPTION OR RISK
As a condition to acceptance of this application, the Agreement must be signed. I understand that attendance of a dog training class is not without risk to myself, members of my family or guests who may attend, or my dog: because of the dogs to which I will be exposed may be difficult to control and my be the cause of injury, even when handled with the greatest amount of care. I hereby waive and release Gangway, Inc. hereinafter referred to as the training organization, it officers, including specifically, but not without limitation, any injury or damage resulting from the action of any dog, and I expressly assume the risk of such damage which I or my dog may suffer, or injury while attending any training session, or any other function or the training organization, or while on the training grounds or the surrounding area thereto. I understand that by signing or executing this form I am releasing Gangway, Inc., its officers and instructors from any liability for damages even if Gangway, Inc., it officers, instructors or any of them are negligent.
In consideration of and a s inducement to the acceptance of my application for training by this Training Organization, I hereby agree to indemnify and hold harmless this Training Organization, its officers and agents from any and all claims by members of any family or any other person accompanying me to any training session of function of the Training Organization, or while on the premises or the surrounding area thereto as a result of any action by any dog, including my own.
I hereby certify that I am over 18 years of age, and of sound and understanding mind.
Dated: ________________________________________
Signed: ___________________________________________
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