Doggie Day Out Application
First Name
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Last Name
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DOB
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Address
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Phone number
*
E-mail Address
*
Drivers License Number
*
Emergency Contact First Name
*
Emergency Contact Last name
Relationship
*
Phone Number
*
Participant Health Insurance Provider
*
Health Insurance Policy Number
*
Group Number (if applicable)
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Participation Date Requested
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Preferred Dog
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Intended locations to visit
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Have you previously owned or handled dogs?
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No
Yes
Are you comfortable handling dogs? (Check all that apply)
No
Yes
Large Dogs
Medium Dogs
Small Dogs
High-Energy Dogs
Shy/Nervous Dogs
Program Rules & Agreement: I acknowledge and agree to the following: • I understand that participation in the MCAS Doggie Day Out Program is voluntary. • I agree to follow all MCAS Doggie Day Out Program rules and instructions. • I understand the dog must remain within Montgomery County at all times. • I agree to keep the dog leashed and under control at all times. • I will not take the dog to off-leash dog parks. • I will not leave the dog unattended in a vehicle or public area. • I understand that MCAS cannot guarantee the behavior or temperament of any dog. • I accept responsibility for safely handling the dog during the outing.
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No
Yes
• I agree to immediately report any injury, illness, bite, escape, or incident to MCAS. • I understand all MCAS equipment and supplies must be returned. • I authorize MCAS staff to deny or terminate participation at any time for safety concerns. • I understand this is not an adoption or foster placement. • I release Montgomery County Animal Shelter, Montgomery County Fiscal Court, employees, volunteers, and affiliates from liability arising from participation in the program except in cases of gross negligence.
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No
Yes
