Spring Classes

Student Name 1 *

First

Last

P1: Date of Birth *

P1: Gender *

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 *

PROGRAM FEES:
JANUARY (3 CLASSES) : $105.00
FEBRUARY (4 CLASSES) : $140.00
MARCH (4 CLASSES) : $140.00
APRIL (4 CLASSES) : $140.00
MAY (3 CLASSES) : $105.00

JAN (3 weeks)
11, 12
18, 19
25, 26

FEB (4 weeks)
1, 2
8, 9
15, 16
22, 23

MAR (4 weeks)*
1, 2
8, 9
15, 16
29, 30
* No Classes Week of March 20 for Spring Break

APRIL (4 weeks)
5, 6
12, 13
19, 20
26, 27

MAY (3 weeks)
3, 4
10, 11
17, 18

* Space is limited and there are 8 participants per class NO EXCEPTIONS.
We are happy to wait list your child and notify you of any opening/ cancellations. Classes will be filled on a first-come/ first serve basis.

EMERGENCY INFORMATION

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: *

~~ ADW staff is not able to administer medications, except under the written emergency plan from a physician. ~~

EMERGENCY CONTACT INFORMATION

Emergency Contact Name: *

First

Last

Emergency Contact Name: *

First

Last

Cell 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

DEMOGRAPHICS

Our student programs and scholarships we offer to students in need of assistance are partially funded by grants. The following questions are OPTIONAL, but your participation can increase ADW's chance of receiving future support to keep these programs thriving.

MEDIA AUTHORIZATION & RELEASE

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

do hereby authorize Assistance Dogs of the West, its successors and assigns, and those acting under its permission and on its authority to copyright, use, and publish in perpetuity for:
- art
- sales materials
- advertising
- promotion, packaging, or trade
- any other lawful purpose whatsoever
- articles written or comments made by me
- photographs, pictures, portraits, images of me and or my dog(s) or other animal(s) in conjunction with my/our own fictitious name
- reproductions thereof in color or otherwise, made through any medium (Film, Video, Print, Website, Social Media)

Any and all comments made by me are provided to Assistance Dogs of the West without receipt of any promise of consideration.

The undersigned warrants that he/she has full power and authority to grant all of the rights conveyed there under and hereby waives any right that he/she may to inspect or approve the finished product or the advertising or other copy that may be used in connection therewith or the use to which it may be applied. The undersigned further agrees that this authorization and release binding upon his/her heirs, executors, administrators, successors and assigns.

The undersigned warrants that he/she is of full agreement and has every right to contract in his/her own name in the above regard, and further that he/she has read the above authorization and release, prior to its execution, and that he/she is fully familiar with the contents thereof.

Media Authorization & Release *

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

WAIVER OF LIABILITY & INFORMED CONSENT RELEASE

I, the undersigned, have volunteered myself to participate in dog training classes, private consultations, workshops or other related activities offered by Assistance Dogs of the West (ADW). By signing hereunder, I certify that I have been informed and understand that there is always some unavoidable risk of injury involved when working with animals, especially animals with behavioral issues. I acknowledge that dogs can be inherently difficult to control and that not all dogs will be under control at all times resulting in the possibility of injury to myself, my dog, my family members, or third parties. Additionally, I have had full opportunity to discuss all concerns I have about the foregoing risks with ADW and its authorized representatives. I have also made all inquiries and investigations to my satisfaction related to such risks, including, but not limited to, an examination of the training area (if applicable). I hereby accept and assume, without reservation, all risks associated with my participation in the Classes, including, but not limited to: the risks of any and all injuries to myself, the dog I am working with, and any of my family members or third parties who may attend; the risks that any dog may cause injury to other persons and/or dogs involved in the Classes; and the risks that saliva, water, food, snow and/or other debris may be present in the training area. As lawful consideration for participating in the classes, I, for myself, my heirs, executors, administrators, legal representatives, successors and assigns (the “Releasing Party”), hereby waive, release, discharge and agree not to sue and to indemnify, defend and hold harmless Assistance Dogs of the West (ADW) and their managers, agents, and employees (the “Released Party”) from any and all injuries, losses, claims and damages to any person or persons of any nature whatsoever, including claims arising from the Released Party’s own negligence, and all costs associated therewith, including attorney’s fees, court costs and consultant fees, arising from my participation in the Classes. This Waiver of Liability & Informed Consent Release shall be legally binding on the Releasing Party. Should the Releasing Party assert a claim to the contrary to what I have agreed to in this Waiver of Liability and Informed Consent Release, the claiming party shall be liable for all expenses (including attorney’s fees, court costs and consultant fees) incurred by both the Releasing Party and the Released Party. No waiver or modification of any provision herein shall be valid unless expressly agreed to in writing by both the Released Party and the Releasing Party. Every provision herein is intended to be severable. If any one or more of the provisions herein is found to be unenforceable or invalid, that shall not affect the other terms and provisions hereof, which shall remain binding and enforceable. YOUR TYPED NAME BELOW SERVES AS YOUR DIGITAL SIGNATURE.

I Have Read the Liability Waiver & Informed Consent *

I Agree to the Waiver & Consent

*PLEASE NOTE WHEN SUBMITTING REGISTRATION FORM TO REFRESH THE PAGE AFTER YOU HAVE CORRECTED ANY RED BLOCKS*

AFTER SCHOOL

EMERGENCY INFORMATION

EMERGENCY CONTACT INFORMATION

DEMOGRAPHICS

MEDIA AUTHORIZATION & RELEASE

WAIVER OF LIABILITY & INFORMED CONSENT RELEASE