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- Dog's Information
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Dog's Information
Dog's Name
Dog's Age
Dog's Birthday
MM slash DD slash YYYY
Dog's Breed
Dog’s Approximate Weight (in pounds)
Dog's Color/Patterns
Gender
Male
Female
Spayed/Neutered?
No
Yes
Pet Parent Information
Parent 1 Name
First
Last
Parent 1 Email
Parent 1 Cell Phone
Parent 2 Name
First
Last
Parent 2 Email
Parent 2 Cell Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Emergency Contact Name
First
Last
Emergency Contact Phone
Who else is authorized to pick up your dog?
Veterinarian Information
Vet Clinic Name
Vet Clinic Phone
Vet Clinic Email
Vet Clinic Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Proof of Required Vaccinations
Rabies
Distemper
Leptospirosis
Bordetella
K9 Influenza
Please Upload Vaccination Records
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 10.
Pre-Screening Questions
Is your dog more than twelve weeks old?
Yes
No
Do you have proof of your dogs current vaccinations?
Yes
No
Has your dog been to doggy daycare before?
Yes
No
Does your dog have any health or physical limitations?
Yes
No
Has your dog ever bitten another dog in an aggressive manner?
Yes
No
Unsure
Has your dog ever bitten a human?
Yes
No
Unsure
Health Information
Allergies
Issues we need to be aware of?
Physical Limitations
Is your dog permitted to have a Nylabone while in the crate when at daycare?
Yes
No
Rate your dogs level of exercise/activity (playing, running) on a daily basis.
Often
Sometimes
Rarely
Never
Pet Personality Profile
How long have you owned your dog?
Age when Spayed/Neutered
Where did you get your dog?
If adopted, describe your knowledge of your dog’s past history.
Number of Adults in Household
Number of Children in Household
How does your dog behave around children?
What other animals are in your house?
How does your dog act with these animals?
Grooming History
How often is your dog groomed?
Professional or At-Home?
Professional
At-Home
Dog's Reaction to Grooming
Do you use flea/tick treatment? If so, what kind?
*
Pet General Behavior
Do visitors bring their dogs to your home?
Yes
No
Rarely
How does your dog react?
How does your dog react to strangers in your home?
How does your dog react to dogs of various sizes?
Does your dog automatically fear or dislike particular types of dogs?
How does your dog react to puppies?
How does your dog react to another dog approaching him/her when you are out on a walk?
Has your dog ever attempted to bite someone?
How does your dog handle being left alone?
How does your dog act when you get home at the end of the day?
How does your dog show he/she is happy?
Has your dog ever climbed or jumped over a fence?
Does your dog have any challenges in the following areas? Mouthing, Housetraining, Barking, Digging, Ignoring commands.
What kind of noises frighten your dog?
What other things frighten or make your dog nervous?
Does your dog growl or snap when food or toys are taken away?
Has your dog ever shared food or toys with other animals?
Does your dog play with toys?
Does your dog like to play with other dogs?
What kind of dogs does your dog like to play with?
Have you taken your dog to the dog park? If so, how do they do?
Pet Communication/Training
Is your dog crate trained?
Yes
No
Has your dog ever had any canine education (obedience) training?
Yes
No
If yes, when and where?
What commands does your dog know?
What hand signals do your dog know?
Does your dog have a “release” word?
Does your dog have a “quiet” command?
Does your dog have potty “cue”?
How often does your dog usually eliminate daily? At what times?
Other
Please add any other comments or information that you feel might be helpful to us in the evaluation process.
How did you hear about The Canine Club?
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About
1624 Beason Street, Baltimore, Maryland 21230
410-539-7626
Mon - Fri: 6:30 AM - 8:45 AM,
9:30 AM - 7:00 PM
Sat - Sun: 9:00 AM - 5:00 PM
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