Puppy Party Registration Puppy Party Registration Pet's InformationPet's Name: DOB: Breed: Color: Sex: Female Male Unknown Neutered Spayed Identifiers (Microchip #, Tattoos, Special Marks, Declawed, AWC #): Acquired at what age: Origin: Breeder Rescue Stray Individual/Friend Other Has your pet ever traveled/lived outside of Alaska? No Yes (States and approximate dates) Who is your puppy's veterinarian? Date of Last Deworming: Date of Last Bordetella (Kennel Cough) Vaccination: Date of Last Canine Distemper/Parvo/Corona Vaccination: Date of Last Rabies Vaccination: Food: Dry Soft/Moist Canned Brand(s): Treats/Supplements: Do you currently have Pet Insurance? Yes No Pet Insurance Company: Please tell us what you would like to accomplish in this class:How did you become aware of our puppy parties? Client InformationThe following contact information is used for CVAC use only, we honor your privacy & security.Name* First Last Co-Owner Name First Last Spouse Parent Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residence address same as mailing? Yes No Residence Address: Street Address Address Line 2 City State ZIP / Postal Code Primary Phone #: Home Cell Work Alt. Phone: Home Cell Work Alt. Phone: Home Cell Work E-mail Address: Authorization* I agree to the terms and conditions.In consideration of the acceptance of this registration, and the holding of classes, and the opportunity to have my dog participate, I agree to hold College Village Animal Clinic, Inc. harmless from any claim for the loss or injury. I personally assume all responsibility and liability for any such claim. By signing this form I am allowing College Village Animal Clinic to use class videos and photos for marketing materials, including the clinic website and social media pages.EmailThis field is for validation purposes and should be left unchanged.