Mosaic Dog Training, LLC
Application form for private or group classes
Name and Contact Information:
Last Name: *
Your answer
First Name: *
Your answer
Email address: *
Your answer
Telephone Number: *
Your answer
Street Address: *
Your answer
City: *
Your answer
Zip Code: *
Your answer
Dog Specific Information:
Dog's Name: *
Your answer
Dog's Age: *
Your answer
Breed of Dog: *
Your answer
Dog's Sex (choose one) *
If your Female is in tact, what is the date of the last heat cycle?
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Where did you get your dog from? If your dog came from a breeder, rescue, or shelter, please include name. *
Your answer
Why did you choose this particular breed and/or dog? *
Your answer
What age was your dog when it came to live with you? *
Your answer
Have you owned a dog before? *
Required
If your answer to the question above was yes, please supply details such as how long ago, multiple dogs, what breeds, etc.
Your answer
Home Environment:
What type/style of home do you live in? (ranch, apartment, bi level for example) *
Your answer
Do you have a fenced in yard? *
If you DO NOT have a fence, how do you keep your dog safe when they are outside?
Your answer
Are there any children living in your home or that visit your home? *
Your answer
If you answered yes to the above question, what are their ages?
Your answer
How many adults are living in your home? *
Your answer
Are there any other pets in your home? *
If yes please supply what and their ages.
Your answer
How does your dog get along with the other pets?
Your answer
How many hours is your dog left alone in your home? *
Your answer
Is your dog crate trained? *
If the answer above is NO, would you want me to assist you in crate training your dog?
If your dog is not crate trained, where do they spend their time when you are gone?
Your answer
Veterinary and Vaccination information:
Please supply the name, address, phone number and email of your Veterinarian. *
Your answer
Date of last Veterinary Visit: *
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***Answer the next question if your dog is OVER 4 months of age***
What is the date of their last Rabies vaccination?
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***Answer the next question if your dog is UNDER 4 months of age***
What number in the Parvo Series has your dog received?
(AVSAB American Veterinary Society of Animal Behavior guidelines state that the first parvo and the first deworming needs to be done AT LEAST 7 DAYS prior to attending a group class. You can read the guidelines here: https://avsab.org/wp-content/uploads/2016/08/Puppy_Socialization_Position_Statement_Download_-_10-3-14.pdf
If my dog is old enough to receive the Rabies vaccine, I will supply a copy of the certificate with my payment at the first class. *
I will also supply a copy of all current vaccination records along with my payment at the first class. *
Does your dog have any medical issues or on any medications that I should be aware of? *
If yes, please list below.
Your answer
Does your dog have any allergies to food or the environment? *
If yes, please list below.
Your answer
If necessary, may I contact your Veterinarian for clarification regarding any of the questions in this application? *
Exercise, Enrichment, Nutrition:
How much exercise (physical and mental) in minutes does your dog get each day? *
Your answer
What types of physical exercise dog your dog receive on a daily basis? *
Your answer
What types of enrichment (mental exercise) does your dog receive on a daily basis? This includes interaction with you. (choose all that apply): *
Required
Other:
Your answer
What brand of dog food do you feed your dog? *
Your answer
How often do you feed your dog? *
Your answer
What quantity of food do they receive each feeding? *
Your answer
Do you free feed (leave food out all the time)? *
What kinds of treats does your dog receive on a daily basis? *
Your answer
Personality and Behaviors:
What are three characteristics, personalities, and/or behaviors you love in your dog? *
Your answer
What behaviors would you like to change in your dog and why? *
Your answer
What would you consider your short term goals (what behaviors are most important to change quickly)? *
Your answer
What would you consider your long term goals? *
Your answer
Has your dog ever snapped at or bitten another animal or human? *
If you answered YES to the above question, please explain in as much detail as you can.
Your answer
Has your dog ever shown resource guarding (being protective of) food, toys, spaces, or you or other people? *
If you answered YES to the above question, please explain in as much detail as you can.
Your answer
Have you and your dog had any formal dog training? *
If yes, where and how long ago?
Your answer
If you received your dog from a shelter, rescue, or another person, to your knowledge, has your dog had any formal training?
If yes, do you know where and how long ago?
Your answer
Training Equipment and Class Choice:
What type of training equipment do you use? Please mark all that apply: *
Required
Please list any other equipment not mentioned above:
Your answer
Would you be willing to try different equipment than what you are currently using? *
Select the desired class or Lesson: (discounts for shelter or rescue dogs) *
Required
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If there is any other information that you feel would be helpful to know that was not already mentioned? (This may include personal struggles, family dynamics, expectations of your dog, potential physical or mental barriers that may need to be addressed, etc.): *
If you answered YES to the above question, please explain below.
Your answer
By attending training classes I acknowledge and agree to allow Mosaic Dog Training, LLC the right to record, film, photograph or capture my likeness in any media now and hereafter developed and to distribute, broadcast, use, or otherwise globally to disseminate, in perpetuity, such media without any further approval from me or any payment to me. *
Participant understands that the group class or private lesson training fees, copies of the vaccination records, DHLPP vaccines, bordetella vaccine, negative fecal test result, and rabies certificate, if applicable, are due on the first group class (orientation WITHOUT dogs) or at the start of the private lesson before training has started. Group class participants are also required to have had a recent well dog check up with their Veterinarian and discussed group class with their Veterinarian and followed all suggestions they may have before participating in a group class. Class fees are non refundable. There will be no make up time for missed classes or lessons unless agreed upon by both Mosaic Dog Training, LLC and the participant. ***Private Lesson sessions will be scheduled no longer than 1 month apart to remain an active client*** *
I will discuss the possibility of a minor attending dog training classes or private lessons with Mosaic Dog Training, LLC BEFORE the start of classes or lessons. I understand that it is not always possible for minors to attend class due to age or class dynamic and is for the safety of all concerned. I understand if it is mutually agreed upon for a minor to be present at group classes or private lessons, that a parent will be required to be present at all times and to sign an additional minor clause in the dog training waiver. *
I acknowledge that creating an effective training program will include research that may involve reaching out to other training professionals. I give Mosaic Dog Training permission to discuss training protocols with other trainers, behaviorists, and/or veterinary behaviorists who they feel can give solid advice in order to provide the best possible training outcomes *
Required
Changes in behavior for the owner and their dog does not occur instantly and will take patience, environment management, training consistency and compliance, behavior modification techniques, and possible referral to more experienced professionals. How long it takes to modify a behavior depends on several factors including but not limited to length of time the behavior has been present, when the behavior first started and whether the lifestyle is compatible with management. There are no guarantees for how a dog will respond even with the best management and training because of several factors which can include but are not limited to life experiences, genetics, early socialization history, and prenatal development. Do you understand it will take training, time and possible additional financial resources to change yours and your dog’s behavior and that there are no guarantees of a change or a cure? *
How did you find out about Mosaic Dog Training? *
Your answer
***PLEASE TYPE YOUR FULL NAME IN THE SPACE BELOW AS YOUR LEGAL SIGNATURE*** *
Your answer
Today's Date: *
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