questionnaire and Agreement
Please use contact form at bottom of page to send message & request PDF form to fill out before our first meet and greet.
City:____________________________ State:__________________________ Zip Code:_________________
Contact Info: Work #:_____________________ Cell:______________________ Text? N____Y____
Name:__________________________ Breed:__________________________ Birth Date:__________________
Age/when acquired?________ Where did you get your dog?___________________________________________
Spayed ____ Neutered____ Date of alteration______________________________________
Name: ________________________ Cell:___________________________
Clinic: _______________________________________ Phone #:___________________________________
Is a payment plan set up in case of an emergency? N____Y____
ABOUT YOUR DOG:
If your dog was adopted, what do you know about his history?
Where have you socialized your dog? ____dog parks ____dog classes ____dog friendly trails
____neighborhood dogs ____ friend’s dogs ____none
Does your dog go to day care? N____Y ____(where?)____________________________________________
Does your dog show any sign of resource guarding? N____Y___
Has your dog ever growled or snapped at anyone? N____Y____
Has your dog ever bitten another dog? N____Y____
Has your dog ever bitten a human? N____Y____
How is your dog around kids?
Does your dog present space guarding or territorial aggression? N____Y____
How does your dog act around other dogs while on a leash?
Does your dog require a muzzle, or specific type of lead or collar other than a flat collar? N____ Y____ Please list______
Is your dog reactive to cats, squirrels, rabbits, chickens? N____ Y____
Does your dog have any fear issues? ex: loud noises, men with sunglasses.. N____Y____Please list________________
Have you ever used a dog trainer before? N____Y____ Whom?_____________________________________________
Does your dog have any allergies? N____Y____Please list_________________________________________________
Are there any treats, food or toys that your dog cannot have? N____Y____Please list____________________________
Does your dog take any medications? N____Y____Please list_______________________________________________
Does your dog have any painful, sensitive areas or hot spots? N____Y____Please list____________________________
Does your dog have any injuries or is your dog prone to injury? N____Y____Please list___________________________________
What types of exercise does your dog normally get?
How is your dog’s recall?
What is your dog’s experience in woods? Does your dog usually go on leash or off?
Is your dog crate trained? N____Y____
Is your dog food-driven, toy-driven or attention-driven?
Does your dog have separation anxiety? N ____Y____
Does your dog have any of the following nuisance behaviors?
____mouthiness ____unwarranted barking ____house training
____digging ____jumping up ____escaping/running
____humping ____leash pulling ____charging dogs/people
Do you have any other pets? N____ Y____ Please list______________________________________
How did you hear about us?
Brick Approved K9 Performance
Standard Customer Agreement, Terms & Conditions
- This agreement covers all of the following services provided by Brick Approved K9 Performance and is made by and between the client listed on the signature block below (“Owner”) and Brick Approved K9 Performance:
Obedience Training, Behavioral Modification, Leash Walking, Pack Walking, Play & Train
- Brick Approved K9 Performance shall be referred to in the following as BK9. BK9 will endeavor to create as safe an environment as possible for the training and play (play is referred to as leash walking, pack walking and Play & Train) of Owner’s dog and will endeavor to offer only sound, safe, and responsible training, training instructions and play. However, Owner recognizes that BK9 is not responsible for any unintentional errors, omissions, or incorrect assertions. Owner understands that the recommendation of any other product or service is not a guarantee of Owner’s satisfaction with that product or service. Further, Owner is and will remain responsible for the actions of Owner’s dog at all times. Owner hereby agrees to abide by the rules and policies of BK9. Owner understands that attendance of dog training and play is not without risk to Owner, members of Owner’s family, Owner’s guests who may attend, or to Owner’s dog.
- Release, Waiver of Liability and Indemnification. Owner hereby agrees to indemnify and hold harmless BK9 its officers, directors, instructors, agents, employees and/or representatives of any and all claims that Owner may be entitled to make, or any claims by a member of Owner’s family, or guests accompanying Owner for injury, death, expense, costs or damages to Owner, Owner’s dog or any handler sponsored by Owner both in session and out of session. In addition, Owner agrees that Owner will defend and indemnify BK9 for any injury, death, expense, costs or damages to any dog handlers or dogs, whether sponsored by Owner or not, or to third parties arising out of Owner’s own actions or the actions of Owners dog. Owner, on behalf of himself or herself, his or her personal representatives, heirs, executors, administrators, agents, and assignees, HEREBY RELEASES, WAIVES, DISCHARGES, AND COVENANTS NOT TO SUE BK9 for any and all liability, including any and all claims, demands, causes of action (known or unknown), or judgments of any kind (including attorney fees), arising from any injury, property damage or death that Owner or his or her dog(s) may suffer as a result of the services provided by BK9 under this agreement, REGARDLESS OF WHETHER THE INURY, DAMAGE OR DEATH IS CAUSED BY BK9 AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM OWNER’S HOME OR DESTINATION FOR SERVICES RENDERED. Owner hereby declares that they have read the above-stated provisions, and agree to accept those responsibilities.
- Proof of current Rabies, Bordetella (canine cough), DHPP, and Canine Influenza Virus vaccines are mandatory for all dogs. A separate vaccination for LEPTOSPIROSIS is highly recommended due to the surrounding forest and wetland. Additionally a preventative control of fleas, ticks, worms and ear mites is highly recommended. Owner gives authorization to BK9 to speak with Owner’s veterinarian and/or their staff to confirm their dog(s) vaccination status, date of surgical altercation and medical history. Owner further understands and agrees that if Owner’s dog becomes ill or otherwise injured and is in need of immediate care, BK9 will transport Owner’s dog to the named veterinary clinic named in attached client questionnaire as the first choice, followed by any veterinary clinic as required, and will attempt to reach Owner prior to care being rendered. If Owner is unreachable, BK9 will have the veterinarian proceed with the treatment deemed reasonably necessary. Owner will assume all financial responsibility for veterinary treatment, and Owner consents to BK9 giving instructions to the veterinarian on Owner’s behalf.
- Owner hereby certifies that Owner’s dog(s) is/are in good health and has/have not been ill or displayed any symptoms of illness in the last 30 days. Owner further certifies that Owner’s dog(s) has/have never harmed or shown aggressive behavior towards any person or any other dog. Owner understands that although their dog(s) may not have previously exhibited aggressive tendencies, an affirmation of such, whether true of untrue, does not relieve Owner of any liability under this section. Furthermore, Owner understands and agrees that if their dog(s) exhibit aggressive behavior it may be isolated from KB9 staff and other dogs in the program, and that if the dog does not respond to commands that in some occasions reasonable forceful actions may be employed by KB9 to protect its staff and/or other dogs currently under its care.
- Owner further understands and agrees that BK9’s Pack Walking and Play & Train is an off-leash or partial off leash program where Owner’s dog(s) is/are allowed to run free in fields, at local fenced in dog parks or on forest trails where there is wildlife which can increase the risk of injuries (possible encounters with porcupines, skunks, etc.) or injuries resulting of scratches, split nails, cuts or muscle strains. Owner hereby gives BK9 permission to administer first aid, CPR and emergency care out on the field in case of an injury.
- Owner further understands and agrees that BK9 will not be held responsible if Owners dog(s) wander away from BK9’s pack and become lost. BK9 will do their very best to help locate the missing dog(s).
- In the case of extreme weather, BK9 reserves the right to cancel any services that would put the health and safety of our staff or our clients in danger.
- In the event that a house key is given to BK9 for services, BK9 will safeguard Owner’s key(s) in a manner consistent with that of the professional pet/home service industry, which includes tagging, coding and storing of the key(s) safely and securely. Any key will be returned promptly upon request. If a combination lockbox is preferred, one will be provided by BK9 and will remain property of BK9. Upon request, Owner gives permission to BK9 to attach said combination lockbox in an insignificant spot (such as a back door or fence post). Owner will be provided with combination to lockbox and will have ful l access for its use at their home.
- BK9 reserves the right to terminate this Agreement at any time for any reason and refuse services or admittance to any dog.
- Owner agrees that his/her dog(s) may be videotaped and/or photographed by BK9 and that BK9 may use any such recordings for its own marketing purposes or to record any aberrant or aggressive behavior for the purpose of documenting such behavior and for no other purpose.
- Owner hereby acknowledges that this Agreement shall be construed in accordance with the laws of the State of Vermont. Owner also acknowledges that the Agreement is intended to be as broad as is permitted by the law of the State of Vermont, and that if any portion of this agreement is held invalid, void or unenforceable; Owner agrees that the remainder shall nonetheless continue in full legal force and effect.
- I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES, AMONG OTHER THINGS, A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT I AM AT LEAST EIGHTEEN YEARS OF AGE:
Signature of Owner:_______________________________________ Date:______________________