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ENROLLMENT APPLICATION

By Bertha Hart,2014-08-17 12:46
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ENROLLMENT APPLICATION

    ENROLLMENT APPLICATION

TODAY’S DATE: ___/___/___

PET PARENT INFORMATION

    First Responsible Party

    First Name: ________________________ Last Name: _______________________________

    Address: ___________________________________________________ Unit/Apt: ________

    City: _______________________ State: ____________ Zip: _____________

    Home Phone: ______-______-_________ Work Phone: ______-______-_________

    Cell Phone: ______-______-_________ Email: _____________________________________

Spouse/Partner

    First Name: __________________________ Last Name: _____________________________

Address: ___________________________________________________________________

    (if same as above just put “Same”) Unit/Apt: ________

    City: _______________________ State: ____________ Zip: _____________

    Home Phone: ______-______-_________ Work Phone: ______-______-_________

    Cell Phone: ______-______-_________ Email: _____________________________________

AUTHORIZED/EMERGENCY CONTACT PERSON

    First Name: ______________________________Last Name: ____________________________

    Home Phone: ______-______-_________ Work Phone: ______-______-_________

    Cell Phone: ______-______-_________ Email: _______________________________

Other people authorized to pick up my pet: ___________________________________________

    ENROLLMENT APPLICATION

PET INFORMATION

    Please fill out this page for each pet

Name: _______________________________ Type (Circle One): Cat Dog

Gender (Circle One): Female Male

Is your pet spayed/neutered (Circle One)? Yes No

Breed: ______________________________ Color/Markings: ___________________________

Weight: __________________ Birthday or Adoption Date: ______/_______/________

PET BACKGROUND

    Please describe any medical conditions or allergies that your pet has:

    _____________________________________________________________________________

Please list all medications:

    _____________________________________________________________________________

Please describe your pet’s food and any special dietary instructions (please include brand of food

    and amount):

    _____________________________________________________________________________

    Has your pet been vaccinated for Rabies, Distemper, and Kennel Cough? Please list and you must provide proof of these Vaccinations from your Veterinarian to Puppy Loft.

    _____________________________________________________________________________

My pet plays best with:

    _____________________________________________________________________________

My pet is best described as:

    _____________________________________________________________________________

A few of my pet’s favorite things:

_____________________________________________________________________________

Has your pet every displayed aggression (i.e. Over Toys or Food, Towards People or Other Pets)?

    _____________________________________________________________________________

Is there anything special that we need to know about your pet (i.e. Special Behavioral Concerns,

    Can Climb Fences)?

    _____________________________________________________________________________

VET INFORMATION

    Hospital Name: __________________________________________ Doctor’s Name:_____________________________

    Address: __________________________________________________________

    City: _______________________ State: ____________ Zip: _____________

Phone: ______-______-_________

    Email: ______________________________Website Address: ___________________________

    ENROLLMENT APPLICATION PAYMENT AUTHORIZATION

Type of Card (Circle One): VISA Mastercard Amex Discover

    Name (as it appears on card):_____________________________________________________

Card Number:

    _____________________________________________________________________________

    CVV (Last 3 Digits on the back of the Visa, MC, or Discover, 4 Digits Printed on Front of Amex):

_____________

Expiration Date: ______ / ______

Billing Address (if same as listed on Page 1 just put “Same”):

Address: ______________________________________________________Unit/Apt: ________

City: _______________________ State: ____________ Zip: _____________

By signing below,

    (1) I acknowledge that the information I have provided on this application is true and correct.

    (2) I hereby authorize Puppy Loft Inc. to charge any balance for any services on my account that are “Past Due” and acknowledge that all payments are due when services or products are rendered.

    (3) I also acknowledge with my signature that this is a valid authorization for Puppy Loft Inc. to charge the above listed credit card or any other card submitted to Puppy Loft Inc. for services or products that are rendered according to the policies of Puppy Loft Inc.

_____________________________________

    ________________________________________

    Signature Date

CLIENT AND RELEASE OF LIABILITY AGREEMENT

    Please initial next to each statement and sign below

    ______I hereby hold harmless and indemnify Puppy Loft Inc. , its agents, officers, sub-contractors, employees, pet

    owners, customers, and potential customers (Indemnified Parties) from any and all liabilities, financial or otherwise, for

    injuries to myself, my pet(s), or any other property of mine which may arise from services that are rendered by The Puppy Loft Inc. or as a consequence of my association with Puppy Loft Inc. except to the extent caused by gross negligence, bad faith, or intentional misconduct of the Indemnified Parties.

    _

    In consideration of the services rendered by Puppy Loft Inc., I agree to assume any all liability financial or otherwise, for the behavior and health of my pet arising in connection with such services. I waive any and all claims,

    actions, or demands of any nature, either foreseen or unforeseen, that I may have against Puppy Loft Inc. relating to the care, control, health, and safety of my pet arising in connection with the services that are rendered by The Puppy Loft Inc. except to the extent caused by gross negligence, bad faith, or intentional misconduct of the Indemnified

    Parties.

    ______I hereby authorize Puppy Loft Inc., its agents, officers, sub-contractors, and employees to

     do whatever they

    deem necessary for the safety, health, and well-being of my pet while under the care of Puppy Loft Inc.

    ______By signing below, I acknowledge that I have read this agreement and release of liability in its entirety and agree to

    the terms. This agreement shall be binding for every time services are rendered by Puppy Loft Inc. on my behalf.

______________________________________

    ________________________________________

    Signature Date

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