Membership Release Form Name * Name First First Last Last Email * Phone * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Emergency Contact * Emergency Contact Phone * Dog's Name * Breed Age Sex * Male Female Spayed/Neutered * Yes No Veterinarian * Veterinarian Phone * Pet Care Authorization and Release: * Nikki Ivey, DogSpeak and its employees/contractors will keep the premises sanitary and properly enclosed and will exercise reasonable care for the safety and well-being of your dog. DogSpeak and its employees/contractors cannot be liable for damage or loss by or to dogs in your home. Owner understands the concept of pet sitting, the DogSpeak Membership and positive training techniques. Your dog(s) may participate in supervised activities related to training. While DogSpeak will exercise extreme caution and discretion with the training and care of your dog(s), there is always a possibility of injury resulting from travel or other dogs and/or humans, either in the home or at a public location. Owner agrees that any injury/illness to their dog during the DogSpeak Membership shall not bring any liability of any type on the part of Nikki Ivey, DogSpeak and/or its employees/contractors. Owner agrees to inform DogSpeak if the dog is showing signs of any illness or physical limitation that may affect training, or behavioral issues that may result in harm or illness to humans or other dogs. Nikki Ivey, DogSpeak and its employees/contractors are authorized by the owner to seek veterinary care, including emergency care, at the owner’s expense. DogSpeak will attempt to contact you before obtaining any care; however, this form serves as the authorization Nikki Ivey, DogSpeak and its employees/contractors needs to obtain veterinarian care for your dog regardless. The owner is responsible for veterinarian expenses and transportation, whether or not the owner was reached in advance. The owner agrees to pay all charges for the DogSpeak Membership. DogSpeak employees/contractors may film parts of your dog’s training for educational purposes. By signing this release, you authorize DogSpeak to film your pet. No compensation will be given to dog owners for video and/or photos. I HAVE READ, UNDERSTAND, AND AGREE TO ALL THE PROVISIONS OF THIS AUTHORIZATION. I will notify Nikki Ivey DBA DogSpeak of any changes to Membership information and assume full responsibility for any additional charges. The owner hereby agrees to waive and release Nikki Ivey, DogSpeak and its employees/contrators from any right that you may have in law to recover medical payments, bodily injury damages, or property damages for any liability regardless of the cost, as a result of any injury resulting from the actions of my dog, any other dog, or any humans. I hereby agree to the pet care authorization form as the owner of the dog. I also certify that my dog(s) is/are in good health and do not show any signs of illness that may be contagious or cause harm to humans or other dogs. Furthermore, I certify that all the information provided about my pet(s) is accurate to the best of my knowledge. I have read, understand, and agree to all the provisions of this form. I have read and agree with the terms of the Pet Care Authorization and Release * I agree I disagree Electronic Signature (Please type your full name) * Date reCAPTCHA If you are human, leave this field blank. Submit