Pender Pet Retreat

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703-591-3304

Daycare Application

Off-Leash Daycare Application

Interested in signing your dog up for off-leash daycare? Fill out the form below and click "Submit", and we will get in touch with you shortly to set up your pet's evaluation!

Dog Information
Owner Name*
First Last
Cell Phone (Primary Phone)*
Contact Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Who is your pet's regular veterinarian?*
Dog's Name*
Is your dog:*
- Male
- Female
When is your dog's approximate date of birth?*
Date Format: MM slash DD slash YYYY
Dog's Breed (If a mix, please list 2 predominant breeds)*
Is your dog spayed or neutered?*
- Yes
- No
In what weight range does your dog fall?*
- Less than 10 lbs.
- 10-30 lbs.
- 30-60 lbs.
- 60-100 lbs.
- Over 100 lbs.
Where did you get your dog?*
- Animal Shelter
- Animal Rescue Group
- Breeder
- Pet Store
- Friend
- Found as Stray
How long have you owned your dog?*
Why are you considering our off-leash play program for your dog? (Select all that apply)*
- To play with other dogs.
- So he/she isn't home alone.
- Separation anxiety.
- Exercise.
- Recommended by a friend.
- Recommended by a pet professional (vet, trainer, etc.)
- Other
Why are you considering our off-leash play program for your dog? (Explain other reason.)*
Which of the following BEST describes your dog's level of socialization with other dogs?*
- None - no knowledge of other dog interaction
- Minimal - on-leash encounters only
- Moderate - some off-leash playtime on occasion
- Extensive - regular visits to dog social events, off-leash dog parks, dog daycare, etc.
Has your dog had any problems previously in an off-leash social environment?*
- Yes
- No
Please explain any problems:*
Has your dog been dismissed from a prior group program?*
- Yes
- No
What reason were you given for the dismissal?*
Health History
What product do you use for flea/tick control?*
Has your dog received his/her flea/tick preventative in the last 30 days?*
- Yes
- No
Does your dog have any allergies?*
- Yes
- No
Please explain your dog's known allergies:*
Does your dog have any physical disabilities?*
- Yes
- No
Please explain your dog's physical disabilities:*
Does your dog have any medical conditions?*
- Yes
- No
Please explain your dog's medical condition(s):*
Does your dog have any bathroom-related issues or concerns?*
- Yes
- No
Please explain bathroom-related concerns:*
Check the box that BEST represents your dog's overall level of exercise:*
- Couch Potato: spends all day sleeping, occasional walks and/or playtime
- Mild Exerciser: short daily walks and/or regular playtime
- Moderate Exerciser: long or multiple walks daily and/or regular playtime
- Athlete: regular jogs/runs and/or regular participation in a dog sport activity such as agility, flyball, frisbee, etc.
Behavior
How does your dog react to children?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to other animals living in the household?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to visitors bringing their animals into the household?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to strangers?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to puppies?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to others approaching them while ON leash?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
How does your dog react to others approaching them while OFF leash?*
- Positive Reaction.
- Indifference.
- Negative Reaction.
- Mixed Reaction.
- Not Applicable.
Does your dog ever growl or bark at anyone passing outside your home or yard?*
- Yes
- No
Does your dog play with other dogs?*
- Yes
- No
Please describe other dogs (sizes, breeds, sex, temperaments, etc.):*
Is your dog willing to share his/her food or toys with other animals?*
- Yes
- No
Please select all commands your dog knows:*
- Sit.
- Stay.
- Wait.
- Down.
- Off.
- Come.
- Heel.
What type of collar/harness do you use to secure your dog?*
- Buckle collar.
- Nylon choke collar.
- Chain choke collar.
- Head collar.
- Prong/Pinch collar.
- Harness - leash clips on back.
- Harness - leash clips on front.
Does your dog have a tendency to jump up on people?*
- Yes
- No
Check any of the following areas where your dog may have behavioral problems:*
- Mouthing
- Housetraining
- Barking
- Digging
- Jumping
- Ignoring Commands
- Other
Describe other behavioral problem(s):*
Are there any particular types of people your dog seems to automatically fear or dislike?*
Has your dog ever growled at someone?*
- Yes
- No
Please explain growling situation:*
Has your dog ever bitten someone?*
- Yes
- No
Please explain human biting situation:*
Has your dog ever bitten another animal?*
- Yes
- No
Please explain animal biting situation:*
Has your dog ever escaped from your yard or residence?*
- Yes
- No
Please explain escape situation:*
Is your dog frightened by thunderstorms?*
- Yes
- No
Is your dog frightened or nervous around anything else?*
Does your dog seem to enjoy playing with toys?*
- Yes
- No
Describe your dogs favorite toys to play with:*
Does your dog get protective around his/her toys?*
- Yes
- No
Comments or other information you feel may be helpful:
By adding my Electronic Signature and the date below, I certify that the information which I have provided on this form is true, accurate, and complete.
Electronic Signature Date
Name
This field is for validation purposes and should be left unchanged.

4508 Upper Cub Run Drive, Chantilly, VA 20151

Pet Retreat

M-F 7:00am - 7:00pm

SAT 7:00am - 5:00pm

SUN 10:00am - 5:00pm

Air Travel / Shipping

MON 9:00am - 5:00pm

WED 9:00am - 5:00pm

THUR 9:00am - 5:00pm

FRI 9:00am - 5:00pm

SAT 9:00am - 5:00pm

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