DOGDAYS
4052 Burns Road
Palm Beach Gardens, FL  33410
Tel (561) 694-7970 Fax (561) 694-9193
www.dogdaysandnights.com

OWNER INFORMATION

First Name: _____________________	Last Name: ________________________
First Name: _____________________	Last Name: ________________________

Address: ______________________________________________________________
	   No. and Street						Apt. #
	   ______________________________________________________________
	   City					State			Zip Code

Home Phone: ___________________	Business Phone: _____________________
Fax No.: _______________________	Cellular / Beeper / Other: ______________
Email Address: __________________ @ ______________________

Emergency Contacts
_________________________________	____________________
Name						Phone
_________________________________	____________________
Name						Phone

Veterinarian Information
_________________________________	____________________
Veterinarian / Clinic Name			Phone

Please List Others Individuals who are authorized to pick up your dog(s):
_________________________________	____________________
Name						Phone
_________________________________	____________________
Name						Phone

____________________
Reviewed By
DOG INFORMATION

Dog Name: _____________________	Date of Birth: __________________
Breed: _________________________	Color: ________________________
Gender: ________________________	Neutered / Spayed: YES              NO
Weight: ________________________

Health Information

Please list vaccination expiration dates:	Rabies (and tag #): _______________
						Parvovirus: _____________________
						Distemper: _____________________
						Bordatella: _____________________

Is your dog on Heartworm medication?					Yes/No
(If yes, what type? __________________________________________________)

Has your dog ever had or now have:
1	Hookworms / Roundworms / Tapeworms / Whipworms?		Yes/No
2	External Parasites:  Fleas / Ticks / Mites / Lice?			Yes/No

Do you use flea and/or tick control treatment on your dog?			Yes/No
(If yes, please specify: 

Does your dog take any regular medications?				Yes/No
(If yes, specify medication, dosage, schedule: _____________________________)

Does your dog have any allergies?						Yes/No
(If yes, please specify eg. food, contact, skin:_____________________________)

Does your dog have skin problems that need special treatment / attention?	Yes/No

Does your dog have any musculoskeletal / joint problems?			Yes/No
(If yes, please explain: _______________________________________________)

Does your dog have sensitive/painful areas where he/she does not like to be
touched?									Yes/No

Feeding Information

What food do you regularly serve your dog? ______________________________
What times of day does your dog eat? ___________________________________
How is your dog’s appetite?  Poor / regular / good / always hungry!
Please list any special feeding information: _______________________________

Background & Personality Profile

Is your dog the only dog in your household?					Yes/No
(If no, how many dogs are there? ______________________________________)

Did you get your dog through: Animal Shelter / Breeder / Pet Store / Friend / Other? 

Are you the dog’s first owner?						Yes/No
(If no, please describe your dog’s background: ____________________________)

Does your dog have problems being alone?			     Yes/No/Sometimes
								     Never Been Alone

Is your dog friendly with:
other dogs?					Yes/No
				children?					Yes/No
				strangers?					Yes/No
(If no, please explain: ________________________________________________)	

Has your dog ever bitten anyone?						Yes/No
(If yes, please explain: _______________________________________________)	

Is your dog afraid of anything in particular (ex. noises, situations)?		Yes/No
(If yes, please explain: _______________________________________________)	

Does your dog socialize with other dogs on a regular basis?			Yes/No
(If yes, please explain: _______________________________________________)

Has your dog ever been bitten?						Yes/No
(If yes, please explain: _______________________________________________)	

Do you always trust your dog with other dogs?				Yes/No
(If no, please explain: _______________________________________________)	

Has your dog ever been dismissed or denied access to any other dog facility?Yes/No

Was your dog ever involved in a dogfight?					Yes/No

Have you ever done obedience training with your dog?			Yes/No  
(If yes, Private training / Group Training / Trained the dog yourself?)
(Training Method Used: ___________________________________)
What does your dog like?:

Walking on a leash
Running in the yard
Sleeping on the sofa
Playing with a toy (any specific toy_________________________________________?)
Playing games with owner (any specific games the dog likes_____________________?)
Playing with other dogs
Chewing on bone or toy
Chewing on furniture, shoes, etc.
Digging
Swimming
Sitting on somebody’s lap
Looking out the window
Barking when he is alone 
Barking when he is excited
Barking when he wants attention
Barking when there is somebody at the door
Stealing food from table/counter
Jumping up on people
Driving in a car
Going to the beach
Other___________________________________________ 

Does your dog have:
Prey drive
Food/toy guarding
Need to destroy
Problems with housebreaking(If yes, please explain: ___________________________)	

What do you like most about your dog? ________________________________________________________________________________________________________________________________________________

What would you like to change in your dog’s behavior? ________________________________________________________________________________________________________________________________________________

AUTHORIZATION, ACKNOWLEDGEMENTS & WAIVER:
AT DOG DAYS’ URGING, I HAVE READ THIS AGREEMENT CAREFULLY & UNDERSTAND IT FULLY.

I hereby authorize Dog Days and Florida Dog Daycare, Inc. (hereinafter individually and collectively referred to as “Dog Days”) to maintain my credit card number on file and charge purchases made and/or services rendered against the card at the prices in effect at the time of the transaction.  All charges are final when made.  In the event that declined or any other unpaid charges remain unpaid, Dog Days reserves the right to assess a finance charge of 15% per annum, or the maximum amount permitted by law, if lower.  In the event that my credit card or billing source cannot process a charge due to insufficient credit or funds, Dog Days may divide the total charges or fee into incremental charges in order to process the entire fee or charges.

I understand that Dog Days reserves the right to refuse use of Dog Days facilities or to rescind the right to attend for pets who, in Dog Days’ sole determination, act aggressively, are undisciplined, evidence inappropriate behavior or who might otherwise be a danger to themselves, other animals or people.  I understand that Dog Days may board my dog in any accommodating area of the premises as deemed necessary in Dog Days’ sole determination and that my dog may be taken off site for training purposes.

I understand that pets are encouraged to socialize and exercise at Dog Days and that injuries to either pets or owners or their guests might reasonably be foreseen to occur within Dog Days’ facilities.  I agree for myself, my pet(s) and my guests and invitees to assume the risks and hazards that may be expected to arise from such use and the presence of animals.  I agree that Dog Days shall not be responsible for injuries or illness to myself, my pet(s), my guests or invitees, or other patrons or their pets who may be injured by my pet or the pet of another or by my acts or omissions or the acts or omissions of my guests and invitees, and I shall indemnify Dog Days for any costs, damages, claims or expenses that may result therefrom.  I further acknowledge that Dog Days shall not be held responsible for any illness, ailment or death that may affect my pet during its visit or stay at our facility or while training offsite.  With respect to myself, my pet and my guests and invitees, I shall hold Dog Days harmless from any costs, damages, claims or expenses that we may incur from our use of the facilities or during training at any location.  I further agree for myself, my pets and my guests and invitees, that we shall be solely responsible for and shall not sue Dog Days or any of its employees, officers, investors, agents, customers, visitors or guests for costs, damages, claims or expenses that we may incur as a result of injury, sickness or other harm to ourselves or my pet(s) while under the care of or from accepting advice or training from Dog Days.

I understand that the behavior of dogs cannot be guaranteed and said behavior may be unpredictable and that some domestic animals are capable of inflicting serious personal injury or death, as well as property damage.  Knowing the risks I agree to assume all those risks including but not limited to; assuming the financial responsibility of any litigation arising from any incident which I, my guests or invitees may be involved. I release, indemnify and hold harmless Dog Days, Florida Dog Daycare, Inc., and Dog Days Holdings LLC and their employees, Officers, Directors, Agents or Contractors from any and all damages or personal injury. I understand that my participation in any event or class or presence on the premises holds some risk. My dog and I may be exposed to challenging, treacherous or unstable footing and I accept all possible risks associated.

If, in my absence, my pet should be injured, become ill or suffer an ailment or is otherwise deemed by Dog Days to require immediate veterinary attention, Dog Days is authorized to consult with my veterinarian.  Dog Days, in its sole discretion is authorized to utilize the services of another licensed veterinarian or administer medicine or give other requisite attention to the pet and the expenses thereof shall be paid my me. I understand that I shall be responsible for any and all charges with respect to such veterinary care.  Further, should I be required to take my pet to a veterinarian after a stay or visit at Dog Days, I shall be responsible for any and all veterinary or other related or unrelated charges; Dog Days shall in no way be responsible for same.  I assume any expense or liability for injuries that my pet(s) may inflict upon any human or other pet while in the facility.  It is expressly agreed by myself and Dog Days that Dog Days’ liability shall in no event exceed the current chattel value of a pet of the same species.

I agree that the names and likenesses of me, my family members and my pet may appear on Dog Days’ website, advertising, printed materials, promotional videotapes, news programs and/or other press, magazine, radio, television and/or internet coverage from time to time.

I specifically represent that I am the sole owner or agent of the owner of my pet, and that I am authorized to board the pet and sign this contract.  I specifically represent to Dog Days that the pet has not been exposed to rabies, distemper or bordatella within a thirty day period prior to being left at the facility and is current on heartworm medication and flea and tick control and free of fleas and ticks.

Any controversy or claim arising out of or related to this contract, or the breach thereof, or as the result of any claim or controversy involving the alleged negligence by any party to this contract, shall be settled in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof.  The arbitrator shall, as part of his award, determine an award to the prevailing party of the costs of such arbitration and reasonable attorney’s fees of the prevailing party.

CREDIT CARD DEBIT AUTHORIZATION
I, ___________________________________, hereby authorize Dog Days to debit my (circle one)  Amex  Visa  MasterCard  Discover  Other______,  for goods and services at the time rendered and for any outstanding invoices.  My account number is:
_________________________________________________	________________	_________________
(Account Number)						(Expiration MM/YY)	(CVV2 Number)
By signing below, I acknowledge that I have read and accept the terms outlined above.
_______________________________________________		___________________
SIGNATURE						DATE