Warren County Humane Society Dog Training Registration Form Date __ /__ /_____ Breed ____________________________ M / F Age _________ Owner ___________________________________ Dog’s name ________________ Address ________________________________________ Phone _____ - ________ Current Rabies Vaccine? Yes / No   Veterinarian _____________________________ Bordetella? Yes / No Common behavioral issues (please check all that apply to your dog)   House soils   Chews   Jumps up   Doesn’t come   Fights   Barks   Pulls on lead   Shy   Digs   Aggressive (Provide brief history of behavior. Use back if necessary) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other problem notes ________________________________________________________ ________________________________________________________________________ Corrections given to date ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Age of dog when obtained _________ From _____________________________________ Litter behavior ____________________________________________________________ House training method ______________________________________________________ Other training _____________________________________________________________ Have you attended training classes before? ____ Where _____________________________ Is this dog a house pet? ________ Exercise schedule _______________________________ Goals for class ____________________________________________________________ _______________________________________________________________________ List any medical concerns ___________________________________________________ Dog’s Medications ________________________________________________________ Diet ___________________ Feeding schedule __________________________________ Family data:   Adults in household ______   Children in household ___________ Occupations ______________________________________________________________ Other pets _______________________________________________________________ Previous pets _____________________________________________________________ IN CASE OF EMERGENCY PLEASE CONTACT: Name ___________________   Phone number _____ - ________

___________________________________________________________  Signature (Parent or Guardian if under 18)

__ /__ /_____  Date

Warren County Humane Society 212 Elm Street Warren, Pa. 16365