Mother Rock Star Dogs
Boarding - Dog Care
Medical/Information Form
Your Information:
Name: _______________________________________
Address: _____________________________________
City: _________________ State: _____ Zip: ______
Phone: (H) _____________ (W) _________________
Pager: ________________ Cell: _________________
E-Mail Address:_______________________________
Veterinarian Information:
Name: __________________________________Phone: _________________
Address: ___________________________________
City: ________ State: ______ Zip: _________
Emergency Information (other than vet):
Name: ___________________________________
Address: _________________________________
City: ____________ State: _____ Zip: _______
Phone: (H) ____________ (W) ____________ Cell ________________
Please attach most recent copy of shot records for all dogs being
boarded.
Please give the last dates your dog received the following vaccinations:
DHLPP (Distemper/Parvo combo): ______________ Rabies: _______________
Bordetella: _________________
* We suggest the Bordetella be given twice a year if regularly boarded.)
Dog’s name, breed and age (please include their birthday):
___________________________________________________________
___________________________________________________________
___________________________________________________________
Feeding Schedule: (Please include brand, amount and regular time of meals)
___________________________________________________________
___________________________________________________________
___________________________________________________________
Medical History/Medication/Special Instructions:
__________________________________________________________
___________________________________________________________
___________________________________________________________
Is your dog allowed to have biscuits, chew toys (what kind), or human food?
______________________________________________________________
______________________________________________________________
1
Additional Information About Your Dog
Has your dog been boarded before? Yes ___ No ___
*Can your dog jump a 4ft fence? Yes ___ No ___
(This is very important as we have 4ft cattle panel fences at our facility. If this is not
suitable for your dog, we can either provide yard play on a long lead or suggest another
boarding facility more appropriate.)
Has your dog been crate trained? Yes ___ No ___
Has your dog been socialized with other dogs? Yes ___ No ___
Has your dog been socialized with men? Yes ___ No___
With women? Yes ___ No ___
With children? Yes ___ No ___
Is your dog aggressive towards strangers? Yes ___ No ___
Is your dog aggressive on walks towards people? Yes ___ No ___
Is your dog aggressive towards other animals, small dogs? Yes ___ No ___
Is your dog leash-free trained? Yes ___ No ___
Is your dog spayed or neutered? Yes ___ No ___
Does your dog have allergies? Yes ___ No ___
If yes, please explain______________________________________________________
_______________________________________________________________________
Has your dog received any formal training? Yes ___ No ___
Please list commands you commonly use to communicate with your dog and their
meaning: ________________________________________________________
_________________________________________________________________
_________________________________________________________________
Please check what applies to your dog:
Dog aggressive ___ People aggressive ___ Jumps up ___ Chews ___ Digs ___
Barks excessively ___ Runs away ___ Unruly ___ High jumper ___ Picky eater ___
Shy ___ Toy possessive ___ People possessive ___ Separation anxiety ___
Escapes ___ if yes, please explain: _______________________________________
Other concerns: _______________________________________________________
Is there anything else you would like us to know about your dog?
How did you hear about us? ___________________________________________
2
Mother Rock Star Dogs
Activities Release and Hold Harmless
I understand and assume the possible risks inherent to all dog related activities involving
my dog(s) while he or she is staying at Mother Rock Star Dogs homestead facility
including environmental hazards that can occur in a rural area due to weather,
improvements or conditions on or near the property. I further understand that this Release
and Hold Harmless Agreement has no time limitation and will remain in effect as long as
my dog(s) participates in any activities connected with Mother Rock Star Dogs, and
applies to all claims related there to.
Although we watch the dogs carefully, and do not take aggressive dogs, socialization can
be hazardous due to all the dogs playing together or playing outdoors. We make every
effort to curtail aggressive activity, but cannot be held responsible for injuries that may
occur.
You may elect the following: (please initial one of the following choices)
I DO give my dog/s permission to have group play: _____________
I DO NOT give permission for my dogs to participate in-group play: __________
In consideration for quality care and treatment of my/our dogs(s) and other
valuable consideration, I hereby release, indemnify and hold harmless the owners,
respective agents, employees, heirs and assigns against any and all claims, causes of
action, damages, including attorney’s fees and/or injuries to my dog(s) and
property. I further release them from any liability or responsibility for any accident,
injury, illness, or death to any dog(s) owned by me sustained by us (me) or by our
(my) dog(s) whether the same be caused by the negligence of Mother Rock Star
Dogs or its officers, agents, employees or otherwise.
In the event my dog/s become ill or in need of medical attention, I give Mother Rock Star
Dogs permission to administer aid and/or to use any available veterinarian, should my
veterinarian not be available. Any expenses so incurred shall be paid by me, the dog
owner, in addition to the fees incurred for services provided by Mother Rock Star Dogs.
If a life or death decision arises while your dog(s) is under our care and you cannot be
reached, would you like us to make decision or wait till you can be reached?
Dogs arriving with fleas and/or ticks will be treated at the discretion of Mother Rock Star
Dogs staff, at the owner’s expense.
Dog Owner Signature ______________________ Date _____________
Printed Name
______________________
3
Mother Rock Star Dogs
Transportation Agreement
Transportation pick-up and drop-off times of visiting/boarding dogs are prearranged by
Mother Rock Star Dogs and agreed upon by the owner/s.
We (I) hereby grant permission for the dog/s named above to travel from their resident or
location of pick-up to the Mother Rock Star Dogs’ homestead facility and to return to
their resident of location of drop-off on any date from (today’s date) on (or to any date in
the future) for reasons of drop off/pick up or for medical/recreational or requested/needed
purposes.
We (I) hereby grant permission for the dog/s named above to travel by a vehicle driven or
operated by an employee/owner of Mother Rock Star Dogs acting within the scope of his
or her duties, or gratuitously by individuals, or by an independent contractor. This
transportation may be a privately owned vehicle.
We (I) accept responsibility to determine that the transportation provided is safe and
reasonable for the purposes intended. We (I) agree that Mother Rock Star Dogs, its
officers, trustees and employees are not negligent in their choice of the transportation and
that we (I) have freely chosen the transportation provided herein. We (I) understand that
we have the option to provide our own transportation method.
We (I) hereby waive, release and discharge Mother Rock Star Dogs, its trustees,
officers, and employees from any claim, demand or cause of action arising out of the
transportation herein provide and agree to indemnify and save harmless Mother
Rock Star Dogs and its employees from all claims for loss, damage, injury or death
sustained by us (me) or by our (my) dog whether the same be caused by the
negligence of Mother Rock Star Dogs or its officers, agents, employees or otherwise.
As owner of the visiting/ boarding dog(s) at Mother Rock Star Dogs, I hereby give
consent for emergency medical care as prescribed by a duly licensed veterinarian. This
care may be given under whatever conditions are necessary to preserve life, limb or well
being of my pet. By signing this form, you acknowledge that you understand and accept
the terms and conditions set forth by this agreement.
Dog Owner Signature_____________________________ Date_______________
Printed Name_______________________
4
Mother Rock Star Dogs
Unaltered Dog Agreement
Due to the unpredictable nature of dogs that have not been spayed or neutered, Mother
Rock Star Dogs requires that you sign this release form in order for us to care for your
animal with your complete understanding.
We may consider accepting unaltered females. Please try not to schedule boarding
reservations within four weeks before or after their heat cycle. We also may consider
accepting unaltered males as long as there are not any concerns of aggression or escape.
I hereby release, indemnify and hold harmless the owners, respective agents,
employees, heirs and assigns against any and all claims, causes of action, damages,
including attorney’s fees and/or injuries to my dog(s) and property. I further release
them from any liability or responsibility for any accident, injury, illness, or death to
any dog(s) owned by me sustained by us (me) or by our (my) dog(s) whether the
same be caused by the negligence of Mother Rock Star Dogs or its officers, agents,
employees or otherwise.
As owner of visiting/boarding dog(s), I hereby understand the risks involved when
boarding my unaltered dog(s). By signing this form, you acknowledge that you
understand and accept the terms and conditions set forth by this agreement.
Dog Owner Signature_____________________________ Date_______________
Printed Name
_____________________________
5
Current Out of Town Information
Dates of Travel Destination Estimated time of Return Best number to reach you Best emergency contact if you cannot be reached Hotel or Lodging information and name under which you will be staying –
Date of last flea/tick treatmentAnything different or new about your dog(s) we should be aware of –
6