IMPORTANT Please indicate to which location you are applying: 2293 Delaware (currently open) or 431 Ellicott St (opening mid-summer) I,  * required , hereby certify that my dog (enter dog's name below)  * required is in good health, is up to date on all vaccinations including Canine Distemper, Parvo Virus, Bordetella, Leptosporosis and Rabies, has not been ill with any communicable disease within the last 30 days and is entirely free from fleas, ticks or any other parasite.  Furthermore, I certify that my dog is not aggressive towards other dogs, children or adults.  I have read and understand the following policies: I understand that I am solely responsible for any harm or damage to structure, equipment, other dogs or people caused by my dog while my dog is attending The Puppy Playpen, LLC. I understand and agree that in enrolling my dog to The Puppy Playpen, LLC, our staff have relied on my representation that my dog is in good health and has not harmed or shown aggression toward other dogs, children or adults. I understand that my dog must be treated with a parasite preventative as well as flea and tick preventative. I understand that The Puppy Playpen, LLC and their staff or volunteers will not be liable for any problems which develop, provided reasonable care and precautions are followed and I hereby release them of any liability of any kind whatsoever arising from my dog's attendance and participation at The Puppy Playpen, LLC. I understand that any problems which develop with my dog will be treated as deemed best by the staff and volunteers of The Puppy Playpen, LLC at their sole discretion, and that I assume full financial responsiblity for any and all expense involved.  My veterinarian's name and contact information is as follows:  * required I certify that I have read and understand the policies of The Puppy Playpen, LLC as stated in the previous pages and that I have read and understand the conditions and statements of this agreement including the policies regarding fees, scheduling, my dog's health status and my dog's behavior towards other dogs, children and adults. ABOUT YOU Parents' Name(s):  * required We live at: Street  * required City/State  * required Zip Code  * required Occasionally, dogs may become ill during their stay with us and will need to be picked up so as not to present a contagion factor to their puppy playmates.  Please provide us with contact numbers below, and indicate the order in which to call. Home Phone 1st 2nd 3rd 4th 5th 6th Work Phone Mom Dad Other Caregiver 1st 2nd 3rd 4th 5th 6th Mom Dad Other Caregiver 1st 2nd 3rd 4th 5th 6th Cell Phone Mom Dad Other Caregiver 1st 2nd 3rd 4th 5th 6th Mom Dad Other Caregiver 1st 2nd 3rd 4th 5th 6th E-Mail Address Mom Dad Other Caregiver Mom Dad Other Caregiver ABOUT YOUR DOG My doggy is a: (breed)  * required He/She is _____ years old! (human years, please!)  * required Gender I am a Boy I am a girl Spayed/Neutered? Yes, I am spayed/neutered No, I am not spayed/neutered Tell us about your dog. He/She is: Please check all that apply! Shy Outgoing Calm Energetic Obedient Mischievous Restful Playful Boisterous Quiet Good on a leash Not so good on a leash His/her Likes/Dislikes are: Children Like Don't Like Being Brushed Like Don't Like Puppies Like Don't Like Getting a bath Like Don't Like Other Dogs Like Don't Like I like to chew: toys furniture shoes limbs my tail other dog's tails My favorite toys are: My favorite treats are: Your Dog's Health!  Please select the appropriate response ALLERGIES I do have allergies I do NOT have allergies Vaccinations I am current with all of my vaccinations Please bring up-to-date record of all vaccinations upon first day of day care, thank you! I am not current with all of my vaccinations Please indicate below which vaccinations are not up to date Creepy Crawlies I do NOT have fleas, ticks, or other parasites I do have fleas, ticks, etc I am currently being treated Infectious Diseases I currently do NOT have any contagious or infectious disease I currently DO have a contagious/infectious disease Please specify: I am currently being treated: Yes No DOGGY MANNERS I know basic obedience commands Yes No I have a problem with mouthiness/biting Yes No I have a problem with barking Yes No I have a problem with jumping Yes No I have a problem with digging Yes No I have a problem with housetraining Yes No I have a problem with (other... please explain) You should also know that I: