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
