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Swim Application

If a question does not apply...simply type "n/a" but DO fill in all the blanks.

Please fill out a SEPARATE FORM for each dog you would like to swim.

* Required fields
Name *
E-mail Address *
Date: *
Home Phone: *
Work Phone: *
Cell Phone: *
Address: *
How did you hear about CANINE AQUATICS? *
Your dog's name: *
Your dog's age: *
Your dog's Breed: *
How long have you had your dog? *
Male/Female? * M
F
Spay/Neuter * Yes
No
If adopted, what knowledge do you have of your dog's past history?
Does your vet know that you are considering Swim Therapy? * Yes
No
May we contact your vet to verify his/her approval? * Yes
No, please void this application.
The name of your dog's veterinarian: *
Your veterinarian's office phone number: *
Has your dog had surgery within the past 12 months? If yes, please describe: *
Is your dog on any medication now? If yes, for what condition is the medication prescribed? *
Please describe your dog's current mobility problems (if any) that you would like to focus on improving with Swim Therapy: back, hips, rear legs, etc. *
Does you dog have any sensitive/painful areas on his/her body? *
Does your dog have any chronic ear problems. * Yes
No
What (if any) flea products do you use on your dog? *
Where are your dog's favorite petting spots? Chest, tummy, etc. *
Has your dog ever been swimming before? If yes, what was his/her reaction to the experience? *
If your dog becomes fearful how has he/she reacted in the past? Trembling, growling, panting, etc. *
Are there any kinds of people your dog automatically fears or dislikes? (men, people in uniform, specific Ethnicities, strangers, etc.) *
Is your dog fearful of any specific objects or noises? *
Does your dog like children? * Yes
No
Tolerates
How does your dog behave around children? *
Are there any kinds of dogs your dog automatically fears or dislikes? *
Are there any circumstances where your dog is aggresssive with other dogs? If, yes, please explain: *
Has your dog ever growled at anyone? If, yes, what were the circumstances? *
Has your dog ever bitten anyone? If, yes, what were the circumstances? *
Has your dog ever growled or snapped at anyone who has taken (or has tried to take) food or toys away from him/her? If, yes, what were the circumstances? *
Does your dog enjoy fetch games? If, yes, what are his/her favorite toys? *
Has your dog had any formal obedience training? Please describe: *
What obedience commands does your dog respond to? *
Is there anything else about your dog that you feel we may need to know, and which might be helpful.
WAIVER AGREEMENT: (1) I understand that participating in activities in and around ANY swimming pool, including CANINE AQUATICS, may involve some risk to myself, my dog, members of my family, or my guests who may be present. * I understand and agree.
I do not agree.
WAIVER AGREEMENT: (2) If it is determined that my dog cannot successfully participate due to temperament difficulties, I will receive either a Single Session refund or a prorated refund on a previously purchased Swim Package. Unless stated otherwise cancellation of Swim Sessions/Packages will not be refunded or prorated. * I understand and agree.
I do not agree.
WAIVER AGREEMENT: (3) I agree to give at least 24 HOURS NOTICE OF CANCELLATION OF APPOINTMENT, or forfeit that session without refund. * I understand and agree.
I do not agree.
WAIVER AGREEMENT: (4) I release CANINE AQUATICS, it's owners, employees, and agents, from any and all liability of any nature, for injury or damage wihich I or my dog may suffer, including any injury or damage resulting from the actions of another dog. I expressly assume the risk of any such damage or injury while attending any Swim Session or other function of CANINE AQUATICS or while on the grounds or surrounding area. * I understand and agree.
I do not agree.
WAIVER AGREEMENT: (5) I further release CANINE AQUATICS and it's entire property on Atlantic Ave. Los Angeles, CA 90066 from any and all claims, or claims by any member of my family, or any other person accompanying me onto the above property. I AGREE TO KEEP MY DOG(S) ON LEASH, AND UNDER MY CONTROL, BEFORE AND IMMEDIATELY AFTER EVERY SWIM SESSION. * I understand and agree.
I do not agree.
Signature to be obtained at first meeting or appointment:

I have read and agree to the Privacy Policy *

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