Name:
Date:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-Mail:
Describe your disability and how it affects your life:
How did you hear about us:
Animals Information
Name:
Breed(s):
Age of Dog (Birth Date):
Neutered:
*Please fax vaccination history to AZG at 1-866-674-3186.
All dogs must be current on vaccinations to attend class.
Services Needed
Service Dog Refresher Classes
Puppy Purchasing Consultation
Recertification
New Service Dog
First time certification for owner trained team
Type of Service Dog interested in: *mark all that apply
Guide Dog
Social / Therapy
Wheelchair Assistance Dog
Alerting Dog
Hearing Dog
Other:
Details:
What are five tasks or goals you need your service dog to perform to assist you:
1)
2)
3)
4)
5)
I understand and agree that Arizona Goldens LLC shall not be liable for any injury or damage to any person,
animal, or property. Arizona Goldens LLC reserves the right to refuse or terminate training services to any
owner trained service dog at any time for any reason. I understand that I must pass all Arizona Goldens LLC
tests and programs in order to be certified, and must be annually re-evaluated and pass recertification tests. I
hereby release any photo/image of my person, likeliness, and name to Arizona Goldens LLC.
Signature:
Date:
