Anne Barea, CPDT-KA Trainer Referral

HSSCM offers referrals for positive-only, CPDT-KA trainers in our area. Trainers are not employed or overseen by HSSCM. Individual trainers’ policies, procedures, or curricula may vary. By clicking on the form, your information will be sent to the individual trainer and they will contact you directly.

Please select one: *

• Weekday Classes – Mornings
• Weekday Classes – Afternoons
• Weekday Classes – Evenings

I would prefer: *

• Group Classes
• Individual Sessions
• No Preference

Dog Owner First and Last Name *

Name(s) of Additional Family Members Attending Training Sessions (spouse, children, etc.)

Address *

Address Line 1

Address Line 2

City

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Zip Code

Email *

Phone *

Best Way to Contact Me? *

• Email
• Text
• Phone Call

Dog's Name *

Dog Breed *

Dog Gender *Intact FemaleSpayed FemaleIntact MaleNeutered Male

Dog Birth Date and Age *

Where Did You Obtain This Dog? *

How Long Have You Had This Dog (months, years)? *

Name/Clinic of Veterinarian *

Date of Last Veterinary Exam *

Please list all medications including heartworm preventative which your dog is currently taking *

Please list any health issues or food allergies your dog currently has *

What are you hoping to gain from this class? *

• Basic Manners
• Socialization
• Other

If other, please list

List problems/issues you hope to solve, any important information about your pup, and what you hope to accomplish *

Have you ever done any type of training with this dog before? *YesNo

If yes, please tell us about the training

What type of dog socialization has your dog been exposed to? How does it react when it meets or sees another dog? *

How does your dog behave when it meets a person it hasn't met before? *

Describe how your dog acts while on a leash *

How best describes your dog's personality? *

• Shy
• Protective of People
• Unsure in New Situations
• Out of Control
• Happy Go Lucky
• Calm and Reserved
• Other

If other, please describe

Dog handling, training & other activities can have risks for you, your family & your dog. By typing my name below, I hereby acknowledge I have voluntarily applied for canine owner/handling training conducted by Anne Barea, CPDT-KA. I fully understand that such training may pose risks to myself, my family & my dog. I freely and knowingly assume these risks. I understand that in no way is the Humane Society of South Central Michigan affiliated with this training, offering only referrals for positive-only CPDT-KA trainers. *

My dog is up to date, or will be brought up to date on core vaccines including rabies prior to the start of classes. *YesNo

Please attach proof of current rabies and other vaccines. We will need proof of current vaccines prior to the first class session.

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