Name of Owner

Phone

Address

City

State

Zip Code

Email Address

Name of Dog

Breed

Age of Dog

AKC Registered AKC Registered Yes No

Where did you get this dog from?

Does this dog have any present or past illnesses or injuries?

Have you ever trained a dog in the past? Have you ever trained a dog in the past? Yes No

If Yes, where?

How did you hear about our classes?

Upload Your Proof of Vaccination Certificates (Optional) You may upload proof of vaccination here (rabies, distemper, etc)File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, js. Max. file size: 5 MB

I authorize the Quincy Kennel Club to use photographs and videos of myself and/or my dog on the Quincy Kennel Club website and other advertising materials. I authorize the Quincy Kennel Club to use photographs and videos of myself and/or my dog on the Quincy Kennel Club website and other advertising materials. Yes No

I have read and agree to the Building Rules

Signature

Date