Owner Name *

First Name

Last Name

Best phone number to reach you while you're away *

(###)

###

####

Have any of your dogs trained with CMDT? *

Yes

No

Date of your departure *

MM

DD

YYYY

Date of your return *

MM

DD

YYYY

Someone we can reach in case of emergency (Someone that is able to pickup your dog should it be necessary) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Does your dog have a history of escaping containment? (jumping fences, digging out, opening gates, destroying kennels, etc.) *

Yes

No

We require the following vaccines (or titer equivalents). Please check-off all vaccines your dog is up-to-date on. *

We will ask for proof of these vaccination records prior to your dog's stay.

Rabies

Distemper/Parvo

Bordetella

Dogs with stitches, open wounds, contagious illnesses, or parasites are not permitted to stay with us in order to minimize risk to themselves and the other dogs. Will your dog be free of these issues at the time of their stay? *

Yes

No

Would you like your dog to receive a departure bath? *

$20-$40 (size and behavior dependent)

Yes

No

Would you like us to transport your dog to/from your home? *

$0.75 per mile from our home (applied both ways with a $15 minimum charge)

No

Pickup from my home

Drop off at my home

If we will be transporting your dog what address will they be picked up from and/or dropped off at?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country