Day Camp Application

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Owner Information

Owner’s Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone

Home:

Work:

Cell:

Please provide at least one number.

Email Address:*

Camper Information

Camper's Name:*

Date of Birth:

Month

Day

Year

Weight:*

Breed:*

Sex:*

Male

Female

Is your camper Neutered or Spayed?*

Yes

Are you a client of Montrose Animal Hospital?*

Yes

If not a client of Montrose Animal Hospital, please tell us what veterinary hospital does your camper go to?

Phone Number of Veterinary Hospital:

Emergency Contact Information

Name:

Emergency Contact Phone:

Home Number:

Work Number:

Cell Number:

Please provide at least one number

Persons authorized to drop off and pick up my camper:

to add more names, click the plus icon

I acknowledge and agree that all the information provided in this Camp Application is complete and accurate to the best of my knowledge. I further acknowledge and agree that I have read, understand and agree to all the terms and conditions contained in the Camp Policies and Procedure and Camper Release, Waiver of Liability, Assumption of Risk and Indemnification Agreement, as they may be amended from time to time, which are attached and fully incorporated into this application by reference. I hereby execute the Agreement for my dog, myself and my heirs, successors, representatives and assigns. I further attest that if I am not the sole owner or representative of the dog subject to this application that my signature is sufficient to enter into this Agreement for and on behalf of any owner or representative.*

I acknowledge and agree

Day Camp Interview Questions

Does your dog have any allergies or medical conditions we should be aware of?*

Yes

If "Yes" above please explain.*

Has your dog ever played with other dogs in a group environment before?*

Yes

Does your dog prefer to play with small, medium or large dogs?*

Has your dog ever shown signs of aggression to other dogs or humans, including growling?*

Does your dog have any history of being attacked or abused?*

Does your dog show any resource guarding behaviors (growling at others when they have a toy, or getting pets from a human? Crouching over a toy and hard staring at other dogs as they get close? Snapping or lunging at other dogs if they come close while your dog has a toy, or is with a human getting affection?)*

Have you ever visited Montrose Animal Hospital before?*

Yes

What is the primary reason for using the Summer Camp Program?*

Behavioral

Socialization

Playtime

Anxiety

Aggression

Other

If "Other" above, please explain.*

Is your dog current on vaccinations?*

Yes

Is your dog current on the Canine Influenza/CIV vaccination?*

Yes

Is your dog up to date on Flea/Tick/HW prevention?*

Yes

How many times a day does your dog eat?*

Is your dog on any medications we should be aware of?*

Yes

If "Yest" above, please explain medications.*

Describe how your dog likes to play with other dogs, also describe what your dog (doesn’t) like other dogs to do.*

Does your dog require any special attention while outside in warm temperatures? Are they prone to overheating or breathing issues?*

Does your dog have a habit of eating toys, plastics, or any other nonfood objects?*

Does your dog get mouthy, play bite or nip at people’s arms/legs or at other dogs legs while running/playing?*

Does your dog suffer from separation anxiety, or stress when in a place without you or when in a new environment?*

Camp Policies, Procedures and Camper Release, Waiver or Liability, Assumption of Risk and Indemnification Agreement

1. Camper Requirements - My camper meets the following Camper requirements. She/he has successfully completed the Behavioral Interview; is at least 6(six) months of age; is spayed or neutered; is current on his/her rabies, distemper, bordetella and canine influenza, leptospirosis vaccinations; is in good general health and free of ticks and fleas. If fleas are found, hospital will treat them at the owner’s expense; is not aggressive or protective of toys. I have completed the Camper Application and have provided MAH with a current and valid credit card number. My camper will enter and exit MAH with a leash.*

Yes, My camper meets the requirements.

2. Personal Property - I agree that MAH shall not be responsible or liable for any lost, stolen or damaged personal property belonging either to me or my camper. I also understand that my camper’s collar may be removed in the play area to prevent injury of any dogs. If my camper causes damages to the MAH facility or equipment I understand I am responsible for the full cost of repair or replacement.*

I agree to personal property policy.

3. Camper Fees - I agree to pay MAH for all services, fees and products with the credit card I have provided in the MAH Camper Application. I give my expressed permission for MAH to run my card numbers for any unpaid camp fees, services and products. I also agree that if I pick up after 6:00pm there will be an additional charge of $20. If I’m more than 15min late, I acknowledge my pet will be required to board overnight and I will be charged the subsequent boarding fees required.*

I agree to camper fees.

4. Aggressive Dogs - My camper is not aggressive. I understand that aggressive dogs are not permitted to attend MAH Summer Camp, and if my Camper exhibits unacceptable behavior, he/she may be separated from the other campers. MAH will use reasonable efforts to consult the camper’s parents about the aggression and ways to address it. Aggressive dogs, however, may be asked not to return to MAH Summer Camp. Such a determination shall be made at the sole discretion of MAH.*

I agree to aggressive dog policy.

5. Abandoned Dogs - No camper may be abandoned at MAH. I agree that I will not neglect to pick up my camper without notification. Any camper that is left at MAH without any contact, intrusion or notification from me, of ability, willingness or plans to pick up by myself or my personal representative or agent, will be considered abandoned up to the third day of such notification failure. I understand that if I abandon my Camper at MAH, MAH will by default become the legal owner and guardian of the camper. MAH will, in its sole discretion, determine whether to try to re-home and adopt the Camper from the MAH location at which he/she was abandoned or will relinquish the camper to an unrelated shelter of its choice.*

I agree to the abandoned dog policy.

6. Duty to Disclosure - I have disclosed and shall continue to disclose on an ongoing basis, any and all medical or other conditions, including but not limited to personality concerns or behaviors that may affect, limit or prevent my camper’s ability to participate in play time or otherwise attend MAH as a camper.*

I agree to the disclosure policy.

7. Camper Participation - I understand participation in play time is at the sole discretion of the MAH and that campers may be separated from other campers or asked to leave for any reason is MAH’s sole discretion.*

I agree to the participation policy.

8. Acceptance and acknowledgment of Camp Participation risk - I fully understand that: (a) there are inherent and potential risks involved with interactions between humans and dogs, as well as between dogs and other dogs, which may result in property damage or bodily injury, including but not limited to, permanent disability, sickness or death to human or dog; and (b) there may be other risks not known to me nor readily foreseeable at this time (collectively “risk”). I fully accept and assume all risks and responsibility for all risks, including, without limitation. All losses, costs and damages incurred as a result of my or my camper’s participation in camp, including any veterinarian expenses incurred on behalf of my dog. Sickness shall be defined to include any illness including but not limited to bordetella or any other form of contagious illness.*

I accept participation risk.

9. Veterinarian Liability and Care - I agree to allow MAH to obtain medical treatment for my camper, if, in its sole discretion it appears that, he/she is ill, injured or exhibits any other behavior that would reasonably suggest that my camper may need medical treatment, If a camper passes away at camp, it will be brought to the hospital side of MAH. I agree that I am fully responsible for the cost of any such medical treatment provided to my camper.*

I agree to the veterinarian liability and care policy.

10. Waiver, Release and Indemnification - I hereby expressly and forever generally waive discharge claims, indemnify release from liability save, hold harmless and defend the covenant not to use MAH and their invitees, sponsors, advertisers, owners, officers, directors, employers, volunteers, agents, leasers, and any parties owning, controlling or having any interest in the property at which the event is taken place, and all other representatives or agents (the “Releases”) from and against any and all injury, liability, claims, litigation, actions, suits, costs, losses, damages, expenses or demands (including reasonable attorney’s fees) of every character what so ever on account of, arising out of, resulting from or relating in any way to (i) any act or omission of the releases, including negligence and (ii) my or my camper’s participation in activities at MAH, or otherwise, I further agree to indemnify, save and hold harmless the releases from any claims, litigation, actions, suits, damages, costs, attorney’s fees, losses or injuries as the result of such claim. I agree that this release shall be binding on me and my successors, heirs, legal representatives and assigns. I also expressly and forever release MAH from any duty to protect me or my dog(s) from injury of any kind, and agree that even MAH chose to implement safety precautions such actions shall not alter the fact that I have released MAH from any duty to protect me or my dog(s).*

I agree to the waiver, release and indemnification policy.

I have read and fully understand the terms of this “Camp Policies, Procedures and Camper Release, Waiver or Liability, Assumption of Risk and Indemnify Agreement” and understand that I have given up substantial rights by signing it and have signed it freely and voluntarily without any inducement, assurance or guarantee and intend it to be a complete and unconditional release of all liability to the greatest extent permitted by law and agree that if any portion of this agreement is held to be invalid or unenforceable, that the remainder of this agreement shall remain in full force and affect. I agree that it is intended that all terms of this agreement control despite any particular statute or law that would otherwise protect me or my dog(s).*

I understand and accept.

Owner's Signature:*

Owner's Printed Name*

First Last

Date Completed:*

Month

Day

Year

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