Rattllesnake Avoidance Clinic

Online Registration Form

Instructions:

Please complete the form and press the submit button at the bottom. (note: It may take a minute or two for the form to submit, after which a form acceptance screen or an ad from Freedback.com will display. Please press the Submit button only once.)

Owner Information:

First Name: Last Name:

Street Address:
                     City:     State:     Zip:
Phone (home) :
   Phone (work):
      Phone (cell):
                 E-mail:
                Preferred contact method:

Dog Information:

Cost of clinic is $70 per dog.

Dog #1

Name:

Breed(s):

Age: Gender:

Has this dog ever attended a snake avoidance clinic before? NoYes

Dog #2

Name:

Breed(s):

Age: Gender:

Has this dog ever attended a snake avoidance clinic before? NoYes

Dog #3

Name:

Breed(s):

Age: Gender:

Has this dog ever attended a snake avoidance clinic before? NoYes

Dog #4

Name:

Breed(s):

Age: Gender:

Has this dog ever attended a snake avoidance clinic before? NoYes

Preferred Schedule:

The rattlesnake clinic is held on the days of Saturday, March 8 and Sunday, March 9, 2008.

What day(s) can you attend?

What part of the day can you attend? 8 AM to noon noon to 5 PM

Payment Information:

[ 1 dog = $70 .........2 dogs = $140....... 3 dogs = $210..... 4 dogs = $280 ]

check here to pay via check (addressed to Jin-Sohl Jindo Dog Rescue). Please mail a check for clinic cost ($70 per dog) to the following address:

Jin-Sohl Jindo Dog Rescue
Rattlesnake Avoidance Clinic
P.O. Box 3174
Quartz Hills, CA 93536-3174

Additional information/comments?

We will email you to confirm your participation, give you the specific time of your appointment, and provide directions.