Training Ventures Information Record
Obedience Program: (circle one)
Beginning, Level 2
Agility Program: (circle one)
Beginning, Novice, Adv
Other
     
 Program start date:                          
    Name Owner/Handler: _________________________________________________
 
    Address: ___________________________________________________________
 
    City: _______________________________________ Zip:                    
 
    Occupation:___________________________________ Owner/Handler Age           
 
    Home Phone: ________-_____________ Other Phone: ________-______________
e-mail: ________________________________________________________
    Call Name of Dog: _____________________________ Dog's Age ______ Sex: M F
 
    Breed: _____________________________________ Spayed/Neutered: Yes No
 
    Date of last Distemper & Parvo inoculations _______/______/_______
 
    Name of Veterinarian: ____________________________________________
    Does your dog have any problems or disabilities which might affect training?
 
 
Have you owned a dog before?        Breed(s)
 
Have you trained a dog before?         When?              Where?         
 
Do you have any hearing or physical handicaps? (explain)
 
 
What goals brought you to this program?
 
 
 
Other Comments:
______________________________________________________
( Please read the following “Waiver, Release and Notice” .
It will be executed prior to the start of training. )
______________________________________________________
 
WAIVER, RELEASE and NOTICE for Instruction / Training
In consideration of Valerie Rutledge, Training Ventures and any designated helpers efforts to provide dog instruction and training, I, the undersigned participant/guardian, hereby and forever waive and release any and all of the aforementioned from any claim, lawsuit, or legal action for claim as a result of some supposed act or failure to act during the course of, or as a result of, his/her instruction and training. Further, I hereby direct any heirs or assigns to respect the intent of this document.
 
Notice is hereby given to any prospective dog training participant/guardian that dog training can be injurious to the participant and/or his/her dog and/or family or guests who may attend training sessions. Failure to follow prescribed training and dog handling guidelines in concert with instruction may result in serious injuries. Some such injuries, among several, are: dog bites, those caused by falls or twists; as well as emotional trauma caused by real or perceived threat of injury. Injuries sustained may result in permanent damage and disability or worsen existing conditions. Death could occur as a direct or indirect result of such injuries.
 
I, the participant/guardian, hereby acknowledge that I/the participant am/is responsible for my/his/her dog and hereby assume the risks of such responsibility. It is further acknowledged that the instructor and/or designated helpers will not be visually observing me/the participant or my/his/her dog or other participants or other dogs at all times and, therefore, I/the participant must assume responsibility for my/his/her and my/his/her own dog‘s safety. I/the participant must remain alert and exercise common sense and judgment to safeguard myself/himself/herself and my/his/her dog as well as others and their dogs.
 
At the beginning of this instructional program, I hereby acknowledge that I have been advised of the potential risks and have had the opportunity to ask questions and receive further elaboration of the risks involved and that I, the participant/guardian, freely accept and assume the risks.
 
It is hereby clearly stated that I, the participant/guardian, by signing this document, waive and release certain legal rights and that, should I sign this document, I have done so of my own free will, without coercion and with notice that I am entitled to seek legal counsel.
____________________________
Participant/Guardian signature
_____________________________
Witness
________
Date