Common Active Dog Injuries Seminar Date MM slash DD slash YYYY Name* Cell Phone*Address* Street Address 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* Where did you hear about Agility Underground?* What type of training are you interested in?* What is your availability?*9am - 12pm12pm - 3pm3pm - 6pm6pm - 8pmWhat days of the week are you available?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Please describe your dog’s previous training taken with us or elsewhere (If Any)Do you crate your dog? Yes No Do you have a separate room or place for your dog? Yes No Do you tie your dog outside? Yes No Do you have an outside kennel / run for your dog? Yes No Where does your dog sleep at night Yes No If on a couch or bed, will your dog vacate the spot at your request? Yes No Is your dog spayed/neutered? Yes No Are your dog’s vaccinations up to date? Yes No Are there other dogs in the home? Yes No If so, list: Can your dog be safely left alone in your house? Yes No Can your dog be safely left alone in your car? Yes No Are there situations when your dog appears stressed? Yes No If so, describe: Have you taken your dog to any training classes? Yes No If so, describe type of class and with whom: Does your dog easily comply with a request to give up anything in his/her possession? Yes No If given a treat, does your dog take it gently? Yes No Can your dog be petted, moved, or interrupted while eating? Yes No Can all family members expect reasonable compliance to reasonable requests? Yes No Is there a family member that your dog disregards or ignores? Yes No so, who? When guests arrive is your dog out of control? Yes No What does your dog do? When at the vet’s office will your dog allow itself to be restrained and/or examined without struggling, growling, or biting? Yes No When you encounter other dogs is your dog out of control? Yes No What does your dog do? What are the situations that cause your dog to growl?What actions do you take? Has your dog ever bitten a person? Yes No If yes, how many times: Describe the bite:Just cause a bruise?Break the skin?Stitches needed?Has your dog been in a dogfight with another dog? Yes No Check all that apply: Neither dog got hurt My dog had a few cuts My dog had at least one puncture wound My dog needed stitches The other dog had a few cuts The other dog had at least one puncture wound The other dog needed stitches Are there situations in which you feel you have little or no control over your dog? Yes No If so, describe: Has your dog ever been on a choke, pinch, or shock collar? Yes No If yes, how long? Is your dog contained by any electronic fencing system? Yes No If yes, how long? Is food left out continually for your dog? Yes No Last visit with a vet? Name of vet: Any health problems? Yes No If so, describe: Any medications? Yes No If so, list: What do you feed your dog? How much per day? What are your goals for your dog? Is there anything else you would like me to know about your dog? My dog has problems with: Men Women Mail or UPS Person Groups of people People walking People coming up from behind People running/jogging People on the other side of a fence or barrier Moving body parts (i.e. someone swinging their arms) Eye contact from strangers Being petted or touched My dog has problems with: Men with (hats, beards, sunglasses, other: (Define)) My dog has problems with: Kids (Ages: (Define)) My dog has problems with: Grooming (Define): My dog has problems with the following inanimate objects: Coats Drainpipes Hats Trucks Sunglasses Manhole covers Gloves Water (bath/lake/river/rain) Boots Gravel Umbrellas Pots and pans dropping Stuffed animals Loud music Papers blowing in the wind Shopping carts Playground equipment Thunder Other My dog has problems with other dogs when they: Make direct eye contact Run Walk Play stand still Approaching head on Approaching fast Sniff my dog’s rear Are on leash Are off leash approach the crate approach the car approach the yard approach the home Puppies Male dogs (Intact or neutered) Female dogs (intact or spayed) Certain Breeds of dogs: Other
