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Temperament Evaluation Form (please print out and fax)

# Human’s Information

# Name__________________ Address___________________________ City_________ Zip_________

Home Phone_______________ Work Phone_________________ Cell Phone_______________

Email Address___________________________ (so we can send you pictures, coupons, videos)

# Where did you hear about us? We like to reward our referrals!!_____________________

# Are you applying for: Day Care____ Boarding____ Training___ Grooming________

# Emergency Contact Information (someone other than yourself) Name____________________ Phone______________________

Vet’s Name_________________ Phone_____________________

# Dog Profile

# Dog’s Name_________________ Dog’s Sex__________ Spayed or Neutered?______________

# Dog’s Breed__________________ Dog’s Age__________ Any kids in the household?________________

# Is your dog mouthy or does he nibble on you?________ Is your dog house trained?___________

# Does your dog bark a lot?__________ What brand of food does your dog eat?___________________

# Does your dog take medications?______ If so, for what?______________ How often?____________

# Does your dog have any past injuries or any current conditions?_______________________________

# Does your dog dig?_____________ Is your dog frightened by any noises?_________________

# Is your dog frightened around anything else?____________________

# What happens when you or somebody else tries to take food or toys from your dog?___________________

# Does your dog share well?______________ What kind of toys does your dog like?___________________

# Does your dog get along well with other dogs?_________

# Does your dog prefer to play with any specific breed or size of dog? Male vs Female?__________________

# Has your dog had obedience training?______

What commands does your dog know?___________________________________________

# Would you be interested in taking obedience classes here at the day care?_______________________

# Does your dog have a bathroom command?________________

# Does your dog have any sensitive area’s on the body?______________________

# Where does your dog like to be pet?______________ How does your dog react to strangers?__________

# Are there any types of people that your dog automatically dislikes or fears?_________________

# How does your dog react to puppies?____________

# Rate your dog’s energy level “1” being very mellow and “10” being a total uncontrollable spaz______

# Does your dog show any destructive behaviors when you aren’t at home?_____________________________________________

# Is your dog aggressive on leash?______ Off leash?_________ Do you walk your dog often?________

# Does your dog jump up on you?___________ On others?______ Does your dog growl?__________

# Is it a play growl or a warning growl?________________

# Has your dog ever bitten anybody?_________ What were the circumstances?____________________

# Has your dog ever jumped or climbed over a fence?________ How high was it?__________________

# ___________________________________________________________________________________

# Office Use Only

# Temperament Test Performed on________________By______________ Pass.............Fail

# Shot Record Verified on________________________By____________________________

#Comments________________________________________________________________

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LIABILITY RELEASE FORM

Please print out, sign and fax to:
Port Jeff: 476-4201 or Ronkonkoma: 467-0226.
You can also mail it to PO BOX 1000, Port Jefferson Station NY 11776.

-Three Village K9 Camp LIABILITY AGREEMENT - This agreement shall be in force from the date signed and for all visits thereafter to The Ruff House., hereafter referred to as ‘THREE VILLAGE K9 CAMP’. I, _____________________________, hereby certify that my dog(s): _________________________________________ is/are in good health and have not been ill with any communicable diseases in the last 30 days; and that my dog(s) has/have current vaccinations for rabies, distemper, parvovirus, parainfluenza, hepatitis (adenovirus) and bordetella. Dogs arriving with fleas and/or ticks may be treated with our own tick/flea preventative at THREE VILLAGE K9 CAMP’s discretion, at my expense. I further certify that my dog(s) has/have not harmed or shown aggressive or threatening behavior towards any person or any other dog, except as disclosed under part 6 (a) and (b) of this agreement. I give authorization to THREE VILLAGE K9 CAMP to speak with my veterinarian and/or their staff to confirm my dog(s) vaccination status, date of surgical alteration, and medical history. .

* 1.THREE VILLAGE K9 CAMP is an open play environment and because dogs’ pack instincts can at times be unpredictable, there are inherent risks, which even when closely monitored, may result in the following: i) transfer of communicable illness such as, but not limited to, bordetella virus (“kennel cough”), and ii) injuries such as, but not limited to, broken nails, sore pads, abrasions, lacerations, punctures and/or cuts etc..

* 2.THREE VILLAGE K9 CAMP and their staff shall not be liable for any injury or damage to any person or persons, animals, or to any property, however caused, which result from the training, behavior, care or grooming of my pet, as well as from any negligence on the part of any other pet owner attending THREE VILLAGE K9 CAMP. I further agree that THREE VILLAGE K9 CAMP shall not be liable for any costs, attorney’s fees or expenses incurred in connection with any claim, action or proceeding occurring as a result of my pet’s participation at THREE VILLAGE K9 CAMP..

* 3.THREE VILLAGE K9 CAMP reserves the right to administer aid and/or use any available veterinarian for my pet should the need arise, whether or not THREE VILLAGE K9 CAMP can reach me or my emergency contact. I assume full financial responsibility for any and all veterinary expenses incurred, in addition to other fees incurred for services provided at or by THREE VILLAGE K9 CAMP..

* 4.I agree to pay the rate for services in effect on the date my dog(s) attend(s) THREE VILLAGE K9 CAMP. Prices are subject to change at any time. No dog will be released until all charges are paid in full. I understand our deposit and non-refundable fee policies...

* 5.I am solely responsible for any harm and/or damage caused by my dog(s) to persons, property or other pets, while my dog(s) is/are attending THREE VILLAGE K9 CAMP. THREE VILLAGE K9 CAMP reserves the right to refuse services or admittance to any dog. Costs for repairs to property will be my sole responsibility.

* 6.(a) I agree that I have given full disclosure of any history of aggressive behavior by my dog, and understand that failure to do so will result in my dismissal from THREE VILLAGE K9 CAMP and no refund shall be given.

* 6.(b) My dog’s behavior now and in the future is solely my responsibility. Should any behavior on the dog’s part now or in the future result in damage to the property, owners, or person of a third party, I agree to assume full liability for any and all such damage, and to absolve THREE VILLAGE K9 CAMP from any and all obligations to pay such damage. .

* 7.I understand that the hours of operation are 6am to 8pm. Monday through Friday, 9am-5pm Saturdays and 11am-1pm Sunday. Dogs not picked up by closing will be subject to an additional boarding charge and will be released the next business day, unless arrangements with THREE VILLAGE K9 CAMP are made to the contrary.

* 8.Should I or my pre-approved agent fail to contact THREE VILLAGE K9 CAMP within 48 hours of the arranged pick up time, my pet may be considered to be abandoned. Any expenses incurred for the transport, overnight care, and/or placement or adoption of said pet shall be paid by me in addition to other fees incurred for services provided by, at, or through THREE VILLAGE K9 CAMP. I hereby grant a lien on said pet for any and all unpaid charges resulting from services provided by, at, or through THREE VILLAGE K9 CAMP.

* 9. I agree that my pet(s) may be videotaped, photographed, and/or recorded. THREE VILLAGE K9 CAMP shall retain the exclusive rights to the results and all proceeds of such tapings, photograph, and recordings with the rights throughout the world, an unlimited number of times in perpetuity, to copyright, to use and to license to others in any manner.

Owners(s)_________________________Facility Rep:_____________________Date:___________