Puppy Party Registration

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This field is for validation purposes and should be left unchanged.

Pet's Information

Pet's Name:

DOB:

Breed:

Color:

Sex:

Female
Male
Unknown

Neutered
Spayed

Identifiers (Microchip #, Tattoos, Special Marks, Declawed, AWC #):

Acquired at what age:

Origin:

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 Information

The 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 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.

...your family's other doctors

PHONE:

ADDRESS:

HOURS OF OPERATION: