Application Form Professional Dog Trainers Program Application Please complete the following information and submit with your application fee. Step 1 of 6 - General Student Information 0% Name* First Last Phone*Cell PhoneEmail* Address* Street Address City State / Province / Region ZIP / Postal Code Program Applying For:* Spring 2013 Fall 2013 Spring 2014 Emergency contact person(s)*NameEmailPhone - HomePhone - WorkPhone - Cell DOG INFORMATIONDo you own a dog?Yes, I would like to bring him/her to the programYes, but I am not bringing him/her to the programNo, but plan to get one before the programNo, I will need to have a dog supplied for meIf yes, your dogs name?AgeSex Male Female Breed?Spayed or Neutered? Yes No No, but plan to have it done prior to course start date Does your dog show, or has it ever shown, any signs of aggression toward (check any that apply) Family members Dogs People Other animals None Is your dog fearful of (check any that apply) Loud noise Dogs People Unfamiliar surroundings None Does your dog have any medical problems that we should be aware of? (List) Any additional information about your dog we should know? If you have more than one dog, please list complete information for all dogs below. All innoculations, including Bordetella (kennel cough), must be up to date prior to commencement of the program. Please send a copy of your dog’s health records prior to start dateDuring the program, if you or your dog should acquire any contagious health condition, the school must be notified immediately for the safety of all participants. Do you plan to drive or fly to Victoria to attend the program? * Drive Fly Other While here, will you have a vehicle suitable for transporting a dog?* Yes No N/A Will you need accommodation?* Yes No Important -The Professional Trainers Program is physically strenuous. Applicants should be in very good to excellent physical condition to successfully complete the program.Would you describe your physical condition as (check one)* Excellent Very good Good Fair Do you have any health condition that would interfere with your progress in the Professional Trainers Program? (ie. knee problems, back problems, arthritis, asthma) Education completed including high school (most recent first).*Name of InstituteLocationProgram of studyDate of last attendance Hobbies/Interests* What assets do you feel that you possess for this course? (ie. knowledge of breeds, previous work with animals, good communication skills, good physical condition, etc)* What are your career objectives after completing this program?* Please submit two letters of reference (not from friends or family) that are either work, education, or character related within 5 days of submitting your application. $250 NON-REFUNDABLE APPLICATION PROCESSING FEE* Price: $ 250.00 CAD 1. I understand that acceptance of this application in no way guarantees admission to the program or course. 2. I understand that Ben Kersen and the Wonderdogs reserve the right to modify or cancel any course without notice or prejudice. 3. I hereby declare that the information I have submitted in this application is true and correct. I permit Ben Kersen to request and/or confirm any information necessary to support my application. I understand that falsifying any documents or information submitted will result in the immediate cancellation of my admission or registration. 4. By checking the box below, I understand that this information along with subsequent information placed in my student record will be protected and used in compliance with the Freedom of Information and Protection of Privacy Act (SBC1992) and the operation of the school. I understand that Ben Kersen gathers and maintains information used for the purposes of admission, registration, and other activities consistent with the administration of education programs. Information that I provide will also be used for non-administrative research purposes. The demographic information collected from the student during application and registration at Post Secondary education institutions in BC is required to ensure accurate assignment of a unique identifier for all people accessing education in the province. Students are required to supply this information in order to complete their registration in courses or programs with Ben Kersen and the Wonderdogs.I Agree to the terms and conditions as included in the disclaimer on this application* Yes
