Date: ____________

Name of dog owner: _______________________________________________________

Address: _________________________________________ City: __________________

State: ______  Zip: ____________    E-mail address : _________________________

Daytime Phone ______________    Home? __  Work? __

Evening / Weekend Phone ________________  Home? __  Work? __

Veterinarian / Animal Hospital _____________________________________________

Dog’s Name ___________________ Breed _________________ Age __________

Sex ____ Spayed / Neutered? ____  How long have you had this dog? _______________

Where did you get this dog (breeder, pet shop, adopted) __________, at what age? _____

If adopted, from a rescue organization or shelter? ___ or from an independent party ____
Has this dog had any obedience training?  Please describe:   ________________________________________________________________________
________________________________________________________________________

Is your dog: (circle all that apply)
  shy      playful     likes to chew     mouthy     vocal     stubborn     dominant
  aggressive     growly      fearful       friendly     calm     a biter       outgoing     timid
  reliable      hyper    dominant      pushy       a digger      willful      loyal      possessive
  reactive      flighty      spooky      a nipper

Has this dog ever shown aggressive tendencies toward people or other dogs?  _______

Has this dog ever bitten a person or another dog? __________

Which membership?   Rambunctious Rover ___  Suave Sadie ___  The Fi-Fi   ______
                                  The Garden ____

Drop in lock box at the park,      |  For Office Use Only
Fax to:  732-783-0224 ,            |  Appt Date/Time: _________________
         or                        |  Billing Cycle Date: ________
Mail to:  P.O. Box 35              |  Rabies:    Monthly Fee: __________
           Kingston, NJ 08528      |  DHLPP:            Paid:  _________