Application for Private Training Client InformationName First Last Home PhoneCell PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Veterinarian Name First Last Veterinarian Phone NumberHow did you hear about us? Pet InformationName Breed AgeGender Male Female Spayed/Neutered Yes No How long have you owned this dog? Is this your first dog? Yes No Where did you get your dog? Breeder Shelter Pet store Stray Other Name of Breeder or Shelter Has your dog had a recent veterinary exam? Yes No Was the appointment due to a behavioral issue? Yes No If yes, please explain.Training/Behavior InformationIn order of priority, what are the top 3 reasons for seeking help for your dog(s)? How long has this been an issue? Second How long has this been an issue? Third How long has this been an issue? Examples of Obedience and Manners Training: recall, sit/stay, heel/loose leash, crate training, jumping on guests, impulse control, etc.Examples of Behavior: excessive barking, reactivity, fear/anxiety, house soiling, fighting with other household pets, fear of people, resource guarding, etc.Has your puppy/dog had any formal training in the past? Where? Does your dog have any allergies? Yes No Please list: Does your dog have aggression toward other animals or people? Yes No If yes, please describe. Has your dog ever bitten another dog or human? Yes No If yes, please describe. Waiver and Assumption of Risk and Agreement to Hold HarmlessI (we) understand that there are inherent risks associated with training, boarding, socializing, walking and working with dogs in general. I (we) understand that the attendance of online, in home, and in the community dog training & behavior services is not without inherent risk to myself, members of my family, guests who attend, or my dog, because some of the dogs to which I (we) will be exposed to may be difficult to control and may be the cause of injury, even when handled with the greatest amount of care.Please Initial(Required) I (we) hereby waive and release Christi McKeen, her employees/volunteers, property owners and managers from any and all liability of any nature, for injury or damage resulting from the action of my dog, or any other, and I (we) expressly assume the risk of any such damage or injury while attending any training or behavior session, or other function of Christi McKeen’s, online, in home, or while in the community.Please Initial(Required) I understand I am solely responsible for any harm my dog(s) may cause to self, trainer, property, other humans or other animals. I understand it is my responsibility to keep my dog(s) under control at all times. I understand all dogs learn at a different rate and that training is an on-going process. I must keep up the training process on my own or dog(s) may revert to previous behavior.Please Initial(Required) I understand I am responsible for representing my dog(s) in a truthful manner, particularly about any dangerous, destructive, or unpredictable behavior, so that Christi McKeen, and her employee’s or volunteers, have full knowledge in order to train or administer behavior modification protocols appropriately.Please Initial(Required) I understand that for the duration of the agreed upon training/behavior package, I will be committed to participate fully, including in between sessions, with daily independent skills practice (homework) with my dog(s). I will take it upon myself to ask questions to clarify any part of training or behavior modification that is unclear, in order to help my dog(s) succeed. I understand that I do not have to do any training method, or allow any training method, to be administered, that I do not feel comfortable with.Please Initial(Required) I understand that should I cancel the day of my session, unless it is due to severe weather, death of pet included in this application, or other catastrophic issue, I will forfeit that day’s payment. I understand that in order to best help my dog(s), each session should be held regularly every week/every other week throughout the duration of the training package, and must be fully completed within one month of the timeframe developed between Christi McKeen and I (we) at the very first session, or risk forfeiting payments already made.Please Initial(Required) In order to secure your first session, full payment must be made, and application filled out completely. Please have available a sturdy collar or harness, a 6’ leash (no flexi leads), and treats that your dog really enjoys. If your dog is working on a behavioral issue, treats should be high value (meat, cheese). If this is an issue, please contact me before the first session, to discuss it. 2lexibru@gmail.com or 774-238- 2526. Please Initial(Required) If there is a second pet, or additional information that you think is important to note that is not addressed on this application, please explain below.By typing my name below, I indicate that I fully understand and agree to the contents of this application:(Required)
