Playgroup Application Client Name*: Email*: Address*: Primary Phone*: Cell Phone: Work Phone: Other Phone: Emergency Contact #1 Name*: Phone*: Emergency Contact #2 Name*: Phone*: How did you hear about Blue Dingo Dog Ranch LLC?* Dog Information - General Dog Name*: Nickname: Sex: MF Spayed/Neutered: YN Age*: Date of Birth*: Breed*: Markings*: ID Tag: YN Microchip: YN Microchip #: Vet Information Veterinarian Name*: Address*: Phone*: Vaccination Date (most recent) Rabies*: Bordetella*: DHLPP*: Other: Fecal Sample Date of last test: Results: Flea and Tick Prevention Does your dog take flea or tick medication? YN If yes, please describe: Dog Information – History How long have you owned your dog?* Where did you get your dog?* If adopted, do you have any knowledge of your dog’s past history? YN If yes, please describe: Dog Information – Health Does your dog have any known medical conditions? YN If yes, please describe: Does your dog have any known allergies? YN If yes, please describe: Does your dog take any medication? YN If yes, please describe: Has your dog been treated for any of the following conditions or diseases in the past 30 days? Check all that apply: Kennel CoughConjunctivitisDiarrheaEar MitesFleasMangeParvo VirusBlood in stoolRingwormWormsVomitingLimpingOther (please describe) Dog Information – Behavior and Temperament Has your dog ever bitten any person or animal? YN Has your dog ever shown any aggressive tendencies toward other animals or people? YN Has your dog ever been possessive of toys or food? YN If yes, please describe: Does your dog have any phobias or fears? YN If yes, please describe: What are your dog’s favorite activities? What kind of exercise does your dog receive each week? Where are your dog’s favorite petting spots? Does your dog have any sensitive areas on his/her body? YN If yes, please describe: Does your dog go to off-leash dog parks? YN Please describe your dog’s behavior while there: Has your dog ever been to daycare? YN Please describe your dog’s behavior while there: Has your dog ever been to obedience training? YN If yes, when and where: Does your dog know any commands? YN If yes, which ones: How is your dog’s behavior in the car?* RelaxedExcitedStressedCar SicknessOther (Please describe) Can your dog be contained by a 4' high fence? YN Can your dog have treats? YN Is there anything else we should know about your dog? Policies Please advise Blue Dingo Dog Ranch LLC of cancelations as soon as possible, one month notice is preferred for billing purposes. If you need to cancel the day of playgroup, please call or text 206-225-0933. Cancelations made less than 24 hours in advance will be charged as regular. Cancelations made for medical or family emergencies are exempt from this policy. Invoices are sent at the end of each month for the upcoming month. All invoices are due within 15 days. A daily surcharge of 1.5% will be added after that time. A $30 fee and cost of collections will be added to returned checks. Blue Dingo Dog Ranch LLC reserves the right to cancel service at any time for any reason. To the best of my knowledge, the information that I have provided above is both accurate and true. Additionally, I have read and agree to the Policies listed above. Your signature (Use your mouse to draw signature below) Printed name Date* [recaptcha]