Test form page Name of Owner/Handler:Phone Number:EmailAddressAddress Line 2CityStateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip CodeName of your dogYour dog's date of birthBreedDate of Rabies VaccineDue Date for Rabies VaccineIs your dog spayed or neutered?YesNoWhy do you want to become a therapy team?How did you find out about CAP and/or the CAP training classes?Have you attended obedience classes or had private training classes?YesNoIf Yes, please list obedience or training classes you have attendedDoes your dog have an American Kennel Club Canine Good Citizen Certificate?YesNoHas your dog ever bitten a person or other dog?YesNoIs there any type of situation that bothers your dog, e.g., men with hats, people with umbrellas?Does your dog have any experience with children?YesNoWhat is your dog's experience with children?Do you or your dog have any physical limitations?By filling out my name below, I am agreeing to the following Agreement and Release Statement. AGREEMENT AND RELEASE In consideration for participating in the Companion Animal Program’s (CAP) Training School, Visitation Program, or involvement in any other CAP activities, I agree as follows: 1) I certify that all information that I have provided and will provide to CAP is true and accurate and can be relied upon by CAP. 2) I represent that my animal has and will have up-to-date Rabies inoculations and those immunizations recommended by my veterinarian. 3) I am aware of the inherent dangers of handling dogs and other animals in settings with people and with other dogs and animals, and I recognize the importance of following safety rules in all situations. 4) I agree that while I am participating in CAP activities, I am solely responsible for the behavior, control and well being of my animal at all times. Therefore, I assume all risks related to CAP activities and release CAP, its officers, directors, members, agents or employees if an injury or damage occurs to me or my animal, whether foreseen or unforeseen, related to the activities, and furthermore save and hold harmless CAP, its officers, directors, members, agents or employees from any claim by me or my family or any other party arising out of my participation in the activities. 5) I assume responsibility for my physical fitness in regard to my ability to perform the functions required for CAP activities. 6) I represent that I have read and understand the contents of this Agreement and Release. Name:Date
