Daycare Evaluation Application

Owner's Name *

First Name Last Name

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Requested Evaluation Date (Mon-Fri)

Date

Requested Evaluation Time

: Hour Minutes AM/PM Option

8:00AM to 2:00PM

until : Hour Minutes AM/PM Option

Dog's Name: *

How often do you plan to send your dog to daycare?

Breed (If a mix, list two predominant breeds in behavior): *

Current Age: *

Is your dog spayed/neutered? We require dogs to be spayed/neutered by 6 months of age for group play in daycare. Nursery School puppies are the exception to the 6 month spay/neuter rule. *

Yes No

Is your dog up to date on the following: *

Rabies Distemper Bordetella/Kennel Cough Fecal test within the past 6 months

Dog's Veterinarian: *

How long have you owned your dog? *

Where did you get your dog? *

Animal Shelter Animal Rescue Group Breeder Pet Store Online Ad Friend Found As A Stray

What knowledge do you have of your dog’s past history?

Why are you considering our daycare program for your dog? (check all that apply) *

Play with other dogs So not home alone My dog has separation anxiety Exercise (primary source) Exercise (secondary source) Recommended by other pet professional (trainer, vet, etc.)

Which of the following best describes your dog’s level socialization with other dogs: *

Has your dog had any problems previously in an off-leash social environment? (Check all that apply) *

No Yes - Altercation or fight at a public dog park Yes - Altercation or fight with a neighbor or friend’s dog Yes - Fearful reaction in a group of dogs Yes - Dismissed from a prior dog daycare or social playgroup program (complete "other" option)

Only complete if you answered yes in above that your dog was dismissed from a prior program. What reason were you given as to why your dog was dismissed? Check each statement below that applies to the situation that resulted in your dog’s dismissal.

My dog was injured, no medical treatment required My dog was injured and required medical treatment Another dog was injured, no medical treatment required Another dog was injured and required medical treatment A person was injured, no medical treatment required A person injured and required medical treatment

Provide any other comments you want us to know about this situation.

Please provide information on other pets in household (breed, age, sex, gender):

Do you have cats?

Yes No

How does your dog get along with your cats? *

How does he react to unfamiliar cats he sees on walks? *

How does your dog get along with other household animals? *

Do any visitors bring their dog(s) to your house? *

Yes No

How does your dog react to a stranger coming into your home or yard? *

Does your dog ever bark or growl at anyone passing outside your home or yard? Yes, No, If yes, please explain. *

Are there any types and/or breeds of dogs your dog seems to automatically fear or dislike? Yes, No, If yes, please explain. *

How does your dog react to puppies? *

How does your dog react to another dog approaching him/her in a park, at the beach, or on a walk? On Leash? Off Leash? *

Does your dog play with other dogs? *

Yes No

If yes, which type?

Males and Females Males Only Females Only

Please describe size, breed, & temperament of the other dogs.

Has your dog ever shared his/her food or toys with other animals? *

Yes No

If yes, how does your dog react to another dog approaching his/her food or toys?

Which commands does your dog know? (please check all that apply) *

Sit Stay Down Come Heel Roll Over Kisses High Five

How did your dog get his/her obedience training? (Please check all that apply)

Attended one group class Attended more than one level of group classes (beginner and intermediate,etc.) Dog was sent to a board and train program Private sessions in home

Which of the following best describes the use of obedience cues with your dog at home? *

What kind of a collar do you use to walk your dog? *

Buckle Nylon/Chain Choke Collar Harness – Leash Clips on Back Harness – Front Clip Head Collar Prong/Pinch

Is it effective in keeping him/her under control? *

What does your dog do to show he/she is happy? *

What does your dog do to show he/she is upset? *

Does your dog have any problems in any of the following areas? If yes, please explain.

Mouthing:

Housetraining:

Barking:

Digging:

Ignoring Commands:

Are there any particular types of people your dog seems to automatically fear or dislike? *

Has your dog ever growled at someone? If yes, If yes, what were the circumstances and how did you respond? *

Has your dog ever bitten a person? If yes, what were the circumstances and how did you respond? Please describe any injuries if there were any. *

Has your dog ever bitten another animal? If yes, what were the circumstances and how did you respond? Please describe any injuries if there were any. *

Has your dog ever climbed/jumped a fence? If yes, what were the circumstances? How high was the fence? *

Has your dog ever escaped from your house or yard? If yes, please explain the circumstances:

How would you describe the energy level of your dog? *

Has your dog ever chased or tried to chase a small animal? If yes, what were the circumstances? *

Has your dog ever chased someone (or wanted to) on a skateboard or bicycle? If yes, what were the circumstances? *

Is your dog frightened by thunderstorms? If yes, describe typical behavior & what specifically helps to relax your dog or calm his/her fear.

Is your dog frightened or nervous around anything else? If yes, please explain.

Has your dog ever growled or snapped at a person who has taken food or toys away from him/her? If yes, what were the circumstances and how did you respond? *

Has your dog ever growled or snapped at another dog who has taken food or toys away from him/her? If yes, what were the circumstances and how did you respond? *

Other comments or information about your dog that you feel might be helpful?

Thank you for the time you spent completing the application form. We look forward to meeting you and your dog on evaluation day. Please contact us if you have any questions on the next steps of the evaluation process.

Daycare Evaluation Application

Dog Information

Household Information

Dog Behavior Information