One Hour Instruction Clinics™

Clinic Registration Form

Please answer all of the following questions:
Name
Address
City
State
Zip
Phone
Email

Please select Clinic you are registering for:	Anxiety Free House-training And Baby makes 4 Four on the Floor
How old is your dog?
What breed is you dog?
Have had dog for	yrs. mos.
Have you ever done any obedience work with this dog?	Yes No
Has your dog ever given aggressive warnings (growled or snapped) toward family?	Yes No
toward strangers?	Yes No
toward other dogs?	Yes No
If yes to this question, please explain in detail.
Has your dog ever bitten anyone or another dog?	Yes No
If yes, please explain.
Has your dog ever been housetrained for a month or more?	Yes No
What you need to bring (or not bring) to workshop: A tablet and pen for note taking Please leave dogs at home. These workshops are lecture style and demo dogs will used when necessary.
Signature
Date
How many people will attend?	One Two
Amount Due
Payment Options
1. Print this form and send it with a check (Make checks payable to Peace of Mind) Mail to: Judith Levy M.Ed. PO Box 8158 Pittsburgh, PA 15217
2. Click the Submit below to e-mail it back to us. Place a check in the box and we will phone you for a credit card number.

P.O. Box 8158 | Pittsburgh, PA 15217

Phone: 412-521-5133

Fax: 412-521-0960