CLINIC REGISTRATION FORM


Name _________________________________

Address___________________________________________________________________

Phone Number ______________________________________

Email Address _______________________________________

Dog's Name___________________________           Age___________      Training Level ___________________
          
                    ___________________________                 ____________                             ___________________

Your Handling/ training experience




Your Goals for the clinic




If you are interested in private lessons please indicate day and am or pm

Waiver/ Release
By entering/ attending this clinic I understand that I am responsible for all costs incurred and all damages as the results of myself,
 my family, my dogs or dogs in my control.  I agree to not hold the land owner, clinic coordinator, clinician or any representative
 responsible for any damages to myself, my dogs or any property.

Signature____________________________________________________          Date__________________________

Mail to Denice Rackley 12002 William Turner Rd  Bennington, IN 47011
         Any Questions : denice.r@lycos.com, cell 605-842-6321 or hm 812-427-2303