Registration & ReleaseDate(Required) MM slash DD slash YYYY Pet Information:Name:(Required)Breed:(Required)Color:(Required)Birthday:(Required) MM slash DD slash YYYY Age:(Required)Sex:(Required)Weight:(Required)Flea/Tick Control Method:(Required) Pets over 6 months old MUST be spayed or neutered before admission will be granted. You pet must use flea control. Please inspect your pet for fleas prior to arrival. Pets that are carrying fleas will not be admitted.Owner Information:Owner's Name:(Required)Owner's Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Telephone:Home:(Required)Work:Cell:Owner's Email:(Required) How did you hear about Bark Play & Stay?(Required)Emergency Contact or Others Authorized to Pick up Your Dog:Name:(Required)Phone(Required)Name:PhoneBackground Information:Your pet’s veterinarian:(Required)Telephone Number:(Required)Is your pet on medication:(Required) Yes NoIf yes, name(s) of medications:Frequency of dosage administration:Feeding Instructions:Has your dog ever bitten or been bitten (if yes explain)(Required)Dog’s behavior with people and other dogs(Required)Has your dog ever climbed or jumped over a fence? How high was it(Required)Has your dog ever ingested blanket, towel or bedding(Required)Other comments or information about your dog that you feel might be helpful:Vaccination Records(Required) Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Supported extensions: jpg, gif, png, pdf.Consent(Required) I agree to the statement below!I CERTIFY THAT (1) ALL OF THE INFORMATION CONTAINED IN THIS BACKGROUND STATEMENT IS TRUE AND ACCURATE AND (2) I HAVE READ, FULLY UNDERSTAND AND ACKNOWLEDGE THE DISCLAIMERS ON THE AGREEMENT ATTACHED HERETO (BELOW). In addition, I understand and agree that (1) if my pet discontinues using Bark, Play & Stay for any reason, I will forfeit the balance of my prepaid visits (if any) and will not, under any circumstance, receive a refund, and (2) prepaid visits are not assignable or transferable. This background statement and the attached disclaimer may be executed in several counterparts, each of which shall be deemed to be an original and all of which together shall constitute one and the same instrument. Signatures exchanged by facsimile shall constitute original signatures for all purposes herein. This is a Contract between Bark, Play & Stay (“Facility”) and the pet owner whose signature appears below (“Owner”). 1. Owner agrees to pay the rate for pet care provided in effect on the date pet is checked into Facility. 2. Owner agrees to pay all costs and charges for special services requested, and all veterinary costs for the pet dur- Bark, Play & Stay Registration & Release Page 2 of 3 ing the period pet is in the care of Facility. 3. Owner agrees that the pet shall not leave Facility until all charges are paid to Facility. 4. Owner consents to Facility using pet’s likeness and waives all claims of compensation for use of such likeness by Facility. 5. By signing this Contract and leaving pet with Facility, Owner certifies to the accuracy of all information given about said pet. 6. Facility shall exercise reasonable care for the pet delivered by Owner to Facility. Owner recognizes and accepts potential risks involved with interactive daycare. It is expressly agreed by Owner and Facility that Facility’s liability shall in no event exceed the lesser of the current chattel value of a pet of the same species or the sum of $500.00 per animal admitted. 7. Owner agrees to be solely responsible for any and all acts or behavior of said pet while it is in the care of Facility, and assume any expense and liability for injury to any human or other animals or damage to facilities caused by the pet. Owner specifically represents that he or she is the sole owner of the pet, free and clear of all liens and encum- brances. 8. Owner specifically represents to Facility that, to Owner’s knowledge, the pet has not been exposed to any conta- gious diseases within a thirty-day period prior to check-in. During the period of this Agreement, Owner also agrees to notify Facility of any known exposure of pet to a communicable disease and hold pet out of attending Facility un- til pet is symptom free for a minimum of seven (7) days or with written veterinary clearance. Owner further agrees to maintain currency of vaccinations as required by Facility policy. 9. All Charges incurred by Owner shall be payable upon pickup of pet. Facility shall have, and is hereby granted, a lien on the pet for any and all unpaid charges resulting from services provided by Facility. 10. If pet becomes ill or injured, or if the state of the animal’s health otherwise requires professional attention, Facility, in its sole discretion, may engage the services of a veterinarian or administer medicine or give other requisite attention to the animal, and the expenses thereof shall be paid by the Owner. Owner gives consent to Facility to act on Owner’s behalf in obtaining emergency veterinary care at Owners expense. 11. Owner indemnifies and holds Facility and its employees harmless for said expenses. 12. This Contract contains the entire agreement between the parties. All terms and conditions of this Contract shall be binding on the heirs, administrators, personal representatives and assigns of the Owner and Facility. 13. Any controversy or claim arising out of or relating to this Contract, or the breach thereof, or as the result of any claim or controversy involving the alleged negligence by any party to this Contract, shall be settled in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof. The arbitrator shall, as part of the award, determine an award to the prevailing party of the costs of such arbitration and reasonable attorney’s fees of the prevailing party.OWNER NAME:(Required)By providing your name in the designated field and selecting the checkbox herein, you hereby acknowledge and agree that this shall serve as your legally binding electronic signature.HiddenBark & Lounge Representative:HiddenBark & Lounge Acceptance Date: 21709
