Canine Action Dog Park
Membership Application
Dog Owner Information
We respect your privacy. This information is used for membership business
only. We will not sell or trade your information.
Name:___________________________________________________________________
Mailing Address:________________________________________________________
City:____________________ State:_______________ Zip:____________________
Phone:___________________ Email:________________________________________
In case of emergency, please contact:___________________________________
Pet Information
| Pet name(s) | Vaccinations up to date. | Weight | Healthy | Breed |
| ____________________ | []yes []no | __________# | []yes []no | ___________ |
| ____________________ | []yes []no | __________# | []yes []no | ___________ |
All dogs neutered/spayed? ---------> []yes []no
Membership
Check one: [] New Member []Renewal
Dues
3 months = $50 |
_______ | |
1 year = $150 |
_______ | |
| Second dog add | 3 months = $25 |
_______ |
1 year = $75 |
_______ | |
TOTAL: |
$ |
_______ |
Signed:______________________________________ Dated:_________________
#_______________
