CLINIC REGISTRATION FORM

Name ________________________________________________________

Address________________________________________________________


Phone Number ______________________________________

Email Address _______________________________________   


Vet contact name/number___________________________________________________________________


Dog's Name____________________            Breed___________           Age______
           
Dog # 2              ___________________________                

Your Handling/ training experience


Your Goals for the clinic


Waiver/ Release
By entering/ attending this clinic I understand that I am responsible for all costs incurred and all damages (including to sheep) as the results of myself, my family, my dogs and dogs I am working or in my control.  I agree not to hold the landowner,  clinic coordinator, clinician or any representative responsible to myself, my dogs or my property.                                                                           

Signature____________________________________________________          Date__________________________
Full payment must be included
Mail to Denice Rackley 12002 William Turner Rd  Bennington, IN 47011
         Any Questions : denice.r@lycos.com, cell 605-842-6321