MEMBERSHIP APPLICATION

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1 NoDa Bark and Board MEMBERSHIP APPLICATION Today s date: OWNER INFORMATION: (Please print) Name: Address: City: _ State: Zip: Home Phone: _ Cell: _ Employer: _ Work Phone: Address: EMERGENCY CONTACT: Name: Phone: _ Is this person the decision maker if we cannot reach you? Yes No PET INFORMATION: Name: _ Breed: _ Color: Age: DOB: Weight: Sex: _ Is your dog spayed or neutered? _ If yes, what age was this done? VETERINARIAN: Clinic: _ Address: _ Telephone: _ Veterinarian s name: OTHERS AUTHORIZED TO PICK UP YOUR DOG: Name: Phone: _ Name: Phone: _ Name: Phone: _

2 GENERAL INFORMATION Dog s name: _ How long have you owned your dog? _ Did you purchase or adopt the dog? _ Where did you get your dog? _ Has your dog ever attended dog day care? Yes No Has your dog ever been boarded? Yes No Your Household: No. of people living there: _ Male/Female adults: _ Male/Female children: _ How does your dog interact with children? _ Are there any other animals in the household? _ How does you dog interact with other animals in the house? _ Health: Has your dog been diagnosed with hip dysplasia? Yes No List any current or chronic medical problems: List any medications your dog is currently taking: Do these need to be given while your dog is out our facility? Yes No Are there any allergies or food sensitivities? Yes No What brand of food do you use? _ How often and how much is your dog fed? _ Dog Behavior: Does your dog have regular interaction with other dogs? Yes No How does your pet act with other dogs or strangers coming into your home or yard? Does your dog bark or growl at other people or other dogs? Yes No Any fears or dislikes? If yes, please describe: Are there certain breeds you dog does not interact well with?

3 How do they react with puppies? Does you dog have separation anxiety when left alone? Yes No Has your dog ever been destructive in the house? Yes No Does your dog stay in a kennel, cage, garage, backyard, or free run of the house? Kennel Cage Garage Backyard Free Run of House How does your dog behave towards other dogs approaching during walks? _ Has your dog ever bitten someone? If yes, describe circumstances: Has your dog ever been into a fight with other dogs? If yes, describe circumstances: Has your dog been known to jump over fences or break out of kennels? Yes No Is your dog frightened or nervous with thunderstorms or any other noises? Yes No Has your dog ever growled or snapped at someone for taking away their toys or food? Yes No Does your dog share food/toys with other dogs? Yes No Obedience Training: Has your dog ever had formal obedience training? If yes, how long ago? _ What commands does your dog know? Are these verbal or hand commands? Verbal Hand Commands Does your dog have a quiet command? Yes No Is your dog crate trained? Yes No Is there any other information about your dog that you would like to share?

4 Noda Bark and Board Pet Care Agreement Daycare & Boarding Owner Agreement This is an agreement between Noda Bark and Board and the Pet owner. Name of Owner: _ Address of Owner: _ Name of Dog(s): _ 1. By signing this agreement and leaving your Pet with Noda Bark and Board, the owner certifies to the accuracy of all information provided to Noda Bark and Board in writing or or orally about the Pet. Noda Bark and Board reserves the right to deny admittance to the Pet or any per for any reason at any time. 2. Owner specifically represents to Noda Bark and Board that, to Owner's knowledge, the pet has not been exposed to any contagious diseases within a 30 day period prior to check-in. Owner represents that each time the pet is brought to Noda Bark and Board, Owner is certifying that the Pet is in good health and has not had any communicable illnesses of any kind for 30 days prior to check-in. Owner agrees that if any fleas or ticks are discovered on the Pet during check-in or at any time during the Pet's stay, Noda Bark and Board might not admit the dog or put it in isolation until the Owner picks it up; or agrees to pay for a flea bath. Owner agrees that the Pet is up to date on all required vaccinations. Required immunizations are Bordetella, Rabies, and Distemper. 3. While Noda Bark and Board makes every effort to ensure that the pets staying with us are healthy by requiring their owners to affirmatively represent that all vaccines for their pet are current. Owner acknowledges and aware that the employees of Noda Bark and Board are not veterinarians and do not have backgrounds in animal medicine, and are not expected to diagnose or detect illness. In addition, Owner ackowledges and is aware that vaccines do not protect against all communicable illnesses that may affect a pet. OWNER ACKNOWLEDGES AND AGREES THAT THEY ARE ASSUMING ALL RISK OF ILLNESS, DISEASE, HARM, OR OTHERISE TO THEIR PET BY ALLOWING THEM TO STAY AT NODA BARK AND BOARD. 4. Noda Bark and Board agrees to exercise reasonable care for the pet during his or her stay, and if applicable, during transport. If pet is transported to or from Noda Bark and Board by Noda Bark and Board staff, owner holds Noda Bark and Board harmless in the event of injury or accident during transportation. It is expressly agreed by the owner that that Noda Bark and Board's liability shall in no event exceed the lesser of the current chattel value of a pet, of the same breed or the sum of $ per animal. 5. OWNER AGREES TO BE SOLELY RESPONSIBLE FOR AND ALL ACTS OF BEHAVIOR OF THE PET WHILE IN THE CARE OF NODA BARK AND BOARD, TO INCLUDE PAYMENT OF COSTS FOR INJURY TO STAFF, OR OTHER ANIMALS, OR DAMAGE TO THE FACILITY CAUSED BY THE PET. 6. Owner understands that Noda Bark and Board utilizes playgroups where dogs interact and co-mingle. Owner agrees that the pet may be removed from a play group at Noda Bark and Board's discretion and not permitted to interact further with other dogs during current or subsequent stays. Owner further understands that when dogs play in groups that nicks and scractches and

5 Noda Bark and Board Pet Care Agreement Daycare & Boarding minor bites may occur. Staff may or may not notify the Owner immediately if the Pet sustains minor injuries. But if the pet is seriously injured, Noda Bark and Board will attempt to notify the Owner IMMEDIATELY. (see item 9). 7. Owner agrees that photographs, recordings, or any other images, may be made of Owner and of his/her Pet(s) by Noda Bark and Board, LLC, its affiliates, and that such may be used for any purpose without compensation, including but not limited to advertising, marketing/and or promotional activities. Owner hereby releases, assigns, and transfers, to Noda Bark and Board, LLC. and its affiliates all rights that he/she may possess or claim to such images, recordings, etc. 8. In an emergency, Noda Bark and Board will to attempt to contact the Owner, the Pet's personal Veterinarian, as well as the emrgency contact provided by the owner; however, such an emergency might not provide the time to do so prior to the administration of care. Owner authorizes Noda Bark and Board to obtain immediate medical attention for Pet from any qualified veterinarian; usually long Animal Hospital, and to transport Pet to and from that veterinarian when Noda Bark and Board deems such medical care is important to Pet's health. Owner grants Noda Bark and Board or it's employees or agent's full power of decision making involving the medical tretament of Pet and agrees to pay for all costs. This applies to any claims for injuries or damages related to such medical care and transport. In the event of a Pet's death the Owner and the emergency contact will be notified immediately. 9. This agreement contains the entire agreement between the parties. 10. Any controversy or claim arising out of relating to this Agreement, shall be settled in accordance with the rules of the American Arbitration Association. The arbitrator(s) shall apply North Carolina Law to the merits of any dispute or claim, without reference to conflicts of law rules. THE PARTIES UNDERSTAND THIS CLAUSE WHICH DISCUSSES ARBITRATION. THE PARTIES UNDERSTAND BY SIGNING THIS AGREEMENT THAT THEY WILL SUBMIT ANY CLAIMS TO BINDING ARBITRATION, AND THAT THIS ARBITRATION CLAUSE CONSTITUTES A WAIVER OF THE PARTY'S RIGHT TO A JURY TRIAL AND RELATES TO THE RESOLUTION OF ALL DISPUTES RELATING TO ALL ASPECTS OF THE RELATIONSHIP BETWEEN THE PARTIES. SIGNATURE: Owner Signature: _ Printed Name: _ For your safety and peace of mind, only approved people will be permitted to pick up your pet. If anyone other than you picks up your pet, we require that they will be listed below. You can edit this list at any time by contacting the front desk. Name: _ Phone: Name: _ Phone: _ Name: _ Phone: _ Name: _ Phone: _

6 Name: _ Phone: _

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