Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="03f8dfc3.jpg"> <bR> </td> <td valign="top" colspan=2 height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0408dfe1esnpes.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Greenbelt Kennels</B></FONT><B>     </B><B>|</B><B>     </B><A HREF="index.htm" TARGET="_top" TITLE="Greenbelt Kennels"><U><B>home</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="Day Care Guidelines"><U>Day Care Guidelines</U></A>   |   <A HREF="id78.htm" TARGET="_top" TITLE="Day Care Policies Procedures"><U>Day Care Policies & Procedures</U></A>   |   <B>Registration Form</B>   |   <A HREF="id53.htm" TARGET="_top" TITLE="Why Use Day Care?"><U>Why Use Day Care?</U></A>   |   <A HREF="id54.htm" TARGET="_top" TITLE="Department of Agriculture Day Care Regul"><U>Department of Agriculture Day Care Regulations</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" height=398 colspan=2 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0408dfc3.jpg"> <div> <I>Registration Form</I></div> <div> <B>Greenbelt Kennels         </B></div> <div> Waggin' Tails Doggy Day Care                                                </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="804" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 ><NOBR><div> Owner's Name:</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Address:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="0c001010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Home Phone:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Work Phone:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Cell Phone(s):</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> E-Mail:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's Name:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's Breed:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's DOB:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 ><NOBR><div> Neutered/Spayed</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's Name:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's Breed:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Dog's DOB:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 ><NOBR><div> Neutered/Spayed:</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Referred By:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="147"><div> Veterinarian:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 WIDTH="147"><div> Program:</div> </tD> <tD VALIGN=TOP><NOBR><div> ___Monthly Commitment Package - 1   2   3   4   or   5   Days Per Week</div> <div> ___10-Day Pass</div> <div> ___Pay-As-You-Play</div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 102 WIDTH="147"><div> Dog Park:</div> </tD> <tD VALIGN=TOP WIDTH="642"><div> ___Permission to participate in trips to the West Des Moines Dog Park.  An additional fee of $10.00 will be charged per trip.  </div> <div>     ______Number of times per week - invoiced at end of month    or</div> <div>     ______Every day your dog attends day care - invoiced at end of month..</div> <div> Note:  The required number of daily trips to the West Des Moines Dog Park to ensure every pet requesting this service will be made if weather permits.  An exception due to staff illness might also be required, for the safety of your pet.</div> </tD> </tR> </TABLE></div> <div> <IMG SRC="07501010.png" border=0 width="1" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Your dog must be current on Distemper (DHLPP), Bordetella and Rabies vaccinations.  Documentation from your veterinarian is required for these vaccinations.  According to the current day care regulations from our licensing agency, all dogs over the age of six months must be spayed or neutered.</div> <bR> <div> Your dog's acceptance into our Day Care is the sole discretion of the Greenbelt Kennels staff.  If your dog is disruptive while at the Cay Care, he/she will not be able to return to Day Care until the problem is resolved.  Your dog's attendance at Doggy Day Care is not without risk.  Every effort will be made by Greenbelt Kennel's Doggy Day Care staff to provide a safe environment for your dog.  If your dog requires emergency medical attention, we will contact you immediately and transport your dog to your veterinarian or to the Greenbelt Kennels' on-call veterinarian.</div> <bR> <div> You are responsible for any damage or injury incurred while your dog is at Day Care.  Veterinarian charges due to injury to your dog or injury to another dog caused by your dog will be the responsibility of you and the owner of the other dog.</div> <bR> <div> I, the undersigned, agree to the above, accept full responsibility for the acts of my dog while at Day Care, affirm my pet is sociable, and release Greenbelt Kennels' Day Care and staff from any and all claims of liability.</div> <bR> <bR> <div> Dog Owner Signature:  _____________________________________________   Date:  __________________</div> <div> <I>                                      (New Students Only)</I>  Temperament Tested by: ________________ on: _______________</div> <bR> </td> </tr></table></body>