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Pampered Puppies LLC
159 Linden Street
Wellesley, MA. 02482

 

 

Release Form

AUTHORIZATION: I certify that I am the legal Owner, or the authorized caretaker of the dog named below.

AGE: I certify that the dog named below is at least 16 weeks old.

VACCINATIONS: I certify that the dog named below is healthy and current on vaccinations for 1) Rabies, 2) DHPP or DA2PP (Distemper, Hepatitis or Adenovirus, Parvovirus and Parainfluenza), and 3) Bordetella (i.e. Kennel Cough). If not provided already, I agree that I will provide Pampered Puppies electronic copies of veterinary records proving vaccinations have been completed at least 14 days in advance of the visit.

GOOD HEALTH: I certify that the dog named below is in good health and not under the care of a veterinarian for a specific illness or ailment at this time.

STERILIZATION: If over the age of 9 months, I certify that the dog named below is neutered or spayed.

FLEAS & TICKS: The dog named below is flea and tick free. If it is observed to have fleas or ticks, a flea/tick treatment will be done and charged to me ($30).

IMMUNE SYSTEM: I understand special-needs dogs, young puppies, and senior dogs naturally have a higher risk of injury, stress-related illnesses, weakened immune system, or exacerbation of any pre-existing condition. As such, by using our facility I am waiving any claim for injury, illness, or even death experienced by the dog named below while in the care of Pampered Puppies.

AGGRESSION: I certify that the dog named below has never bitten or displayed aggression toward other dogs or toward people.

All dogs must pass a behavior assessment in order to participate in group activities. No dog will be admitted to daycare or training class who shows any signs of aggression. Any dog that demonstrates aggression or other behavior deemed unacceptable by Pampered Puppies staff may be dismissed and/or crated.

RIGHT OF REFUSAL: Pampered Puppies reserves the right to refuse admittance to any dog or dismiss any dog that does not meet or maintain the health, temperament or other daycare standards. The determination shall be made at the sole discretion of Pampered Puppies.

PERSONAL PROPERTY: I am solely responsible for any harm, including to other dog(s), to employees, or to invitees of Pampered Puppies, or to the equipment, facilities, or other property of Pampered Puppies, caused by my dog(s). I also agree that Pampered Puppies shall not be responsible or liable for any lost or damaged personal property belonging to me.

RELEASE OF LIABILITY: I understand and accept that during normal dog play, the dog named below may sustain injuries. Dog play is monitored by Pampered Puppies staff, but scratches, punctures, torn ligaments, and other injuries may occur despite supervision. I further understand and agree that Pampered Puppies, nor any of its employees, will be liable for any illness, injury, death, and/or escape of my dog provided that reasonable care and precautions are followed. I hereby release Pampered Puppies staff of any liability of any kind whatsoever arising from or as a result of my dog visiting Pampered Puppies.

I hereby certify that I have read and understand this Waiver and Release of Liability. By signing this agreement, I agree to be bound by its terms and conditions.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Dog

Name: *

Birth Date: *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Dog

Name: *

Birth Date: *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Dog

Name: *

Birth Date: *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Dog

Name: *

Birth Date: *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Dog

Name: *

Birth Date: *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Dog

Name: *

Birth Date: *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Dog

Name: *

Birth Date: *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Dog

Name: *

Birth Date: *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Dog

Name: *

Birth Date: *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Dog

Name: *

Birth Date: *
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Dog

Name: *

Birth Date: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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