AGILITY ABILITY    
wINTERF

REGISTRATION  & SCHEDULE

    Winter Classes begin Jan 27, 2018

Saturday Class Dates:
January 27th, February 10th, March 3rd,
March 17th, April 7th & April 28th

Please pay through any of our three easy options:

1) Paypal button below
2) Mail payment to Agility Ability: 3351 Cheshire Rd., Delaware OH 43015
3) County Funding by emailing Connie a PAS from your Service Provider

4) Scholarships are available by signing form on Contact Us page, available one time per year

upon availability!   today!

Classes/tTimes
Tshirt Sizes
Classes with Scholarship

*Our classes are held at Agility & Rally for Fun (ARF)
 1000 Morrison Rd. Ste. 100
facility in GAHANNA, OHIO


AGILITY ABILITY
REGISTRATION & WAIVER
Winter 2018
  Participants must be a minimum of age 5 to attend classes
Payment will be accepted through Paypal on this website, or by mailing a check
along with this completed Waiver/Registration form.
Registration is accepted on a first received basis.  
Acceptance/Acknowledgment of your registration & payment will be sent via email
 (or phone call) once received.

Please copy and print the registration form below and send the completed form & payment to mailing address:

Agility Ability

c/o Connie Will
3351 Cheshire Rd.
Delaware, OH 43015

Refunds will NOT be issued once classes begin
Scholarship Available with filled out form (see Contact Page)
DATES:  Saturdays, Jan 27, Feb 10, Mar 3, Mar 17, April 7, April 28
I would like the 10 a.m. class time______
I would like the 11 a.m. class time______

 
REGISTRATION FORM
:

PARENT/GUARDIAN NAMES:____________________________________________________________________

 

Participant’s Name:_______________________________________________________

Age & D.O.B________________________

 

ADDRESS:____________________________________________________________________________________________________________________________________________

EMAIL ADDRESS:__________________________________________________________________
 

CELL NUMBER: (may we text you?)____________________________________________________ yes __  no __
            

HOME PHONE NUMBER:___________________________________________________________________

 

EMERGENCY CONTACT NUMBER:___________________________________________________________________

 

Participant's Diagnosis \(or explanation if  necessary): __________________________________________________________________________

__________________________________________________________________________
Is your child on any medication that we need to be aware of: __________________________________________________________________________

__________________________________________________________________________

Is your child potty trained? :__________________________________________

Does your child have any condition(s) that may interfere with camp such as:
Oppositional Behavior Disorder, Defiance disorder, Resistance to being with a stranger, difficulty functioning in a social setting
If yes, please describe:__________________________________________________________________

_____________________________________________________________________________________

Is your child able to communicate? (if no, how does she/he communicate with others):______________________________________________________________________________

_____________________________________________________________________________________
Participant's Likes/Dislikes/Fears:___________________________________________________________________________

Does your child have an unhealthy fear of dogs/animals? (if yes, please explain): ________________________________________________________________________________________________________________________________________________________________________________________

Does your child get frustrated often? (If yes, what are some early warning signs that your child is becoming frustrated with a task)? ________________________________________________________________________________________________________________________________________________________________________________________

Is your child afraid of loud or sudden noises?________________________________________________________________________________

What strategies or techniques are used with your child to promote positive behaviors? ________________________________________________________________________________________________________________________________________________________________________________________

What strategies or techniques are used to discourage negative behaviors that will enable us to work safely with your child? ________________________________________________________________________________________________________________________________________________________________________________________

ANY FOOD ALLERGIES?
___________________________________________________________________________
HOW DID YOU HEAR ABOUT US?_______________________________________________________________________

Waiver/release from Liability  for

Agililty Ability  &  Columbus All Breed Training Facility

             In consideration for being allowed to participate in agility programs, work with agility trainers, staff and volunteers, use agility equipment, work with agility dogs, and enter the premises where activities will be held by Agility Ability and Columbus All Breed Training Facility, the undersigned, on his or her behalf, and on behalf of the minor identified below, and those persons or entities set forth in numbered paragraph 3, acknowledges and agrees that:

 1) There is a risk of injury from participation in the activities engaged in, and while particular rules, equipment and personal discipline may reduce the risk, the risk still exists and is accepted and assumed by me; and

 2) I knowingly and freely assume all such risks, both known and unknown, and however arising, even if arising from an agility dog or from the negligence of other participants, volunteers, staff and employees. I will assume full responsibility for the participants listed below. I agree to assume liability for all medical costs, attorneys’ fees and any and all other expenses and damages resulting from injury to myself, the participants listed below and those persons and entities set forth in numbered paragraph 3 below, and

 3) I, for myself and on behalf of my spouse (if any), children, heirs, hereby release and hold harmless Agility Ability and Columbus All Breed Training Facility and its employees, volunteers, and all other participants with respect to any and all expenses, medical bills, causes of action, claims, injury, disability, loss and damage to person or property to the fullest extent permitted by law.

______________________________________________

 Participant Name

 
______________________________________________

 Adult Guardian Name

 

 _______________________________________________

 Adult Guardian Signature

For Agility Ability use:   Paid Amt: _______________   Check #______________ Date Rcvd.______________

 

AGILITY ABILITY PHOTOGRAPH/PUBLICATION RELEASE FORM

We request permission for your child___________________________________________ to have his/her picture taken or to be videotaped by a member of Agility Ability Dog Agility Therapy Team.  If permission is granted by signing below, your child’s picture and/or name, may be used in newspaper articles, television stories, brochures, websites and other promotional publication and video productions.

 

____  Yes, I give my permission

 

____ No, I do not give my permission

 

 

Parent or Guardian’s Signature

 

 

Date

  **YOU DO NOT NEED TO SIGN THE Photograph Release Form
AGAIN IF YOU HAVE DONE SO ALREADY.**


 
Please make checks payable to Agility Ability

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