Balanced K9s New Client In-take
Please complete this form to the best of your ability.

Contact us at (312) 883-2258 or amy.siracusa@balancedk9sllc.com
Email address *
Pet Parent Information
Full Name *
Your answer
Address *
Enter full address including City, State and Zip Code.
Your answer
Phone Number *
Numbers only please
Your answer
Pet's Information
Pet's Name *
Your answer
Breed: *
Your answer
Pet's Age *
Your answer
Veterinarian *
Your answer
Current Vaccinations *
Vaccinations will be checked at the beginning of the first session. Select all that apply:
Required
Dietary restrictions -- Pet or Family *
Please list any allergies in the "Other" category
Please list any behavior concerns:
Your answer
Prior Training History
In this section, I will be collecting background information on how much prior training you have received. If you have trained with another trainer, or in a facility please list: where, when, who, what, and how long in the other category.
What previous training have you had with your pet? *
Service Information
Service Requested *
Please select the service you are interested in purchasing. If unsure please select: Other
Additional notes:
Your answer
How much time per day are you willing to invest in training? *
Service Agreement
LIABILITY:

I, the participant, identified above, for myself, my heirs, executors, administrators and assigns, hereby agree to release and hold harmless Balanced K9s and it’s affiliates, as well as its officers, directors, instructors, agents, employees, and/or representatives from any actions, suits, claims, losses or demands of any kind, which I, my heirs, executors, administrators and assigns may have by reason of any matter arising from or in connection with my participation in Balanced K9s training services.

I understand that Balanced K9s works to provide the safest training environment for my pet. I recognize that Balanced K9s is not responsible for any unintentional errors, omissions, or incorrect assertions. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service.

PAYMENT:

Payments are due prior to the first session. All payment plans must be complete prior last session.

There are two options to pay:

Full payment is made prior to first session.

Payments can be made online or in person (via card, cash or check). All major credit cards accepted. A 3% service fee will be added to all in-person credit card transactions. Online payments can be made via PayPal and sent to: paypal.me/AmySiracusa or completed through Acuity at time of purchase.All payments will receive a copy of invoice and confirmation of received payment within 24 hours.

Payment plans:

Payment plans are available upon request, client must directly contact Amy. Payment plans will be billed automatically via your authorization on a designated account at the time of purchase in accordance with your designated plan. All payment plans will have a one time $10 fee applied. All payment plans must be complete prior to last session.

Travel outside of 20 miles will include an $1.50 charge per mile.

CANCELLATIONS:

For sessions canceled less than 24-hours in advance, there will be a fee of $50. All prepaid sessions do expire after 3 months of inactivity. All packages will be allotted 2 cancellations per 6 week period (1 cancellation per 4 week period), so long as they are not made less than 24-hours in advance.



I have read and agree to the service agreement. *
Required
I have completed the registration to the best of my ability. *
By typing my name below, I understand that I am certifying this enrollment waiver and that it is equivalent to signing my name on a physical document.
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