Spring Classes

Student Name 1 *

First

Last

P1: Date of Birth *

P1: Gender *

Parent / Guardian 1 *

First

Last

Cell Number *

Work Number *

Parent / Guardian 2 *

First

Last

Cell Number *

Work Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Primary Phone Number *

Email *

WEDNESDAY PROGRAM FEES:
JANUARY (4 CLASSES) : $120.00
FEBRUARY (4 CLASSES) : $120.00
MARCH (3 CLASSES) : $90.00
APRIL (5 CLASSES) : $150.00
FULL SEMESTER : $430.00 ($50 Discount)

THURSDAY PROGRAM FEES:
JANUARY (4 CLASSES) : $120.00
FEBRUARY (4 CLASSES) : $120.00
MARCH (3 CLASSES) : $90.00
APRIL (5 CLASSES) : $150.00
FULL SEMESTER : $430.00 ($50 Discount)

REFUND POLICY (PLEASE READ CAREFULLY): Refunds will be given for cancellations made no less than 7 days in advance of the program start-date, minus a 20% administration fee. Any cancellation made less than 7 days prior to the first day of class results in forfeiture of the registration fee. I understand that if my student misses a class, there are no refunds and the student may not attend another day as a make-up session. *

Yes, I have read the refund policy and agree to the above terms.

Payment Method * *

CHECK. Make payable to: Assistance Dogs of the West. Send to: Assistance Dogs of the West, P.O. Box 31027 Santa Fe, NM 87594. Disregard the payment screen after you hit SUBMIT if you have chosen to send a check. CREDIT CARD

My child has the following health problems/ disabilities (for example: allergies, bad knees, diabetes, asthma, seizures, heart problems etc...) *

My child has the following allergies: *

My child may take non-prescription pain medication if the need arises *

YES NO

My child requires the following action for allergic reactions or medical emergencies: *

Is there anything else we should know about your child? *

Emergency Contact Name: *

First

Last

Emergency Contact Name: *

First

Last

Cell Number *

Physician *

First

Last

Phone Number *

Dentist *

First

Last

Phone Number *

Health Insurance Co *

Policy Number *

I authorize Assistance Dogs of the West to seek medical attention for my child in case of an emergency *

Yes No

In the case of a medical emergency, I authorize the Assistance Dogs of the West staff to contact 911, and have my child transported to the nearest hospital. *

Yes No

Successfully attending and completing this after-school program does not signify that the attendee is a service/assistance dog trainer or qualified to train and/or place service/assistance dogs. Assistance Dogs International has specific standards that an individual must meet in order to be an assistance dog trainer – and taking part in this class does not meet these requirements. *

I Understand

For (Participant(s) Name): *

Subject to the terms and conditions set forth in this Agreement, I, *

Media Authorization & Release *

Yes, I Agree to the Media Authorization & Release. No, I Do Not Agree to the Media Authorization & Release.

I Have Read the Liability Waiver & Informed Consent *

I Agree to the Waiver & Consent

Participant(s) Name(s) *

Parent / Guardian Name *

Date *

Contact ADW
Mailing Address:
P.O. Box 31027
Santa Fe, NM 87594

Physical Address:
1590 San Mateo Lane
Santa Fe, NM 87505

Phone & Fax:
505.986.9748
fax: 505.989.9640
toll free: 866.986.3489

Office Hours:
M-Th: 9:30 a.m. – 5 p.m.
Friday: 11:00 a.m. – 2:30 p.m.

Apply for a Service Dog:
Read our FAQ and access our application.

AFTER SCHOOL

WEDNESDAYS & THURSDAYS :
3:45 - 5:15 P.M.
Assistance Dogs of the West
1590 San Mateo Lane
Santa Fe, NM 87505

EMERGENCY INFORMATION

EMERGENCY CONTACT INFORMATION

MEDIA AUTHORIZATION & RELEASE

WAIVER OF LIABILITY & INFORMED CONSENT RELEASE

AFTER SCHOOL

WEDNESDAYS & THURSDAYS :3:45 - 5:15 P.M.Assistance Dogs of the West1590 San Mateo LaneSanta Fe, NM 87505

EMERGENCY INFORMATION

EMERGENCY CONTACT INFORMATION

MEDIA AUTHORIZATION & RELEASE

WAIVER OF LIABILITY & INFORMED CONSENT RELEASE

WEDNESDAYS & THURSDAYS :
3:45 - 5:15 P.M.
Assistance Dogs of the West
1590 San Mateo Lane
Santa Fe, NM 87505