Social Club Registration Form
Today’s Date: ________
The Basics
Parent’s Name: _________________________________________________________
Dog’s Name: ___________________________________________________________
Breed: ________________________________________________ Sex: MN / FS / M / F
Dog’s Birthdate: _____________________ Age: ________ years and ________ months
Age When Altered: __________ How long have you owned your dog?______________
Street Address: _________________________________________________________
City: ____________________________ State: ______ Zip Code: _________________
Email Address: _________________________________________________________
Phone H/C: _________________________ Work Phone: ________________________
Emergency Contact
Name: ___________________________ Phone Number: _______________________
Name: ___________________________ Phone Number: _______________________
Veterinarian Information
Name: ___________________________ Phone Number: _______________________
Street Address: _________________________________________________________
City: ____________________________ State: ______ Zip Code: _________________
License Number/Microchip/Tattoo Number: __________________________________
Other People Authorized To Pick Up
Name: ___________________________ Name: _______________________________
Do you want a password, just to be on the safe side? __________________________
Medical Information
Currently Medications? Y / N
If yes, what kind? _____________________________
Given During Daycare? Y / N
If yes, instructions: ____________________________
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Flea treatment in the past month? Y / N
Preventative Used: ___________________
Your Dog must be current on all Vaccinations! (Parent Must Submit Written Proof)
Rabies: Y / N
DHLP: Y / N
Bordetella: Y / N
Any medical illness in the past? Y / N
If yes, please explain: ___________________
______________________________________________________________________
Any ongoing medical conditions that we need to be aware of? ___________________
______________________________________________________________________
Basic Care Information
Any allergies or sensitivities, food or otherwise? ________________________________
Please explain any restrictions on play, activity, etc.: ____________________________
______________________________________________________________________
Favorite games/toys? ____________________________________________________
What commands does your dog know? ______________________________________
Favorite petting spot? ____________________________________________________
Areas sensitive to being touched? __________________________________________
Behavior Questions
Other pets in the household? Y / N
How do they get along? ___________________
How does your dog react to other dogs or people in your home or yard? ___________
______________________________________________________________________
Are there any types of people, or anything particular that make your dog nervous? ___
______________________________________________________________________
Has your dog ever bitten anyone aggressively? Y / N
Circumstances? ____________
______________________________________________________________________
Ever growled at or jumped on anyone aggressively? Y / N
In what way? _________
______________________________________________________________________
Any bad habits? ________________________________________________________
Housetraining? _________________________ Barking? ________________________
Digging? ____________________ Ignoring commands? ________________________
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