Canine Classic Spa & Resort
2405 Springfield Rd.
Bloomington, IL  61701
New Client Information/ Daycare Application
Owner’s Information
Name________________________________________________________________________________
Address_________________________________________City________________________Zip________
Home Phone____________________ Work Phone_____________________Cell Phone______________
Email address_________________________________Spouse’s Phone____________________________
Employer________________________________________ Address______________________________
Spouse’s employer________________________________Address_______________________________
Emergency Contact_____________________________________Phone___________________________
Pet Information
Name____________________________   _____________________________  _____________________
Breed____________________________  _____________________________  _____________________
Male/Female       N/S                                            Male/Female    N/s                            Male/female    N/S
Birthdate_______________________        ___________________________       ____________________
Vaccination Records:  date given              Veterinarian’s Name __________________________________
Rabies________________________            __________________________    ______________________
DHLPP________________________             _________________________      ______________________
Bordetella_____________________            _________________________        _____________________
Distemper(cats)________________            _________________________         _____________________
Other________________________            __________________________       ______________________
I,_________________________, hereby certify that me pet(s) are in good health and have not been ill with any communicable disease in the last 30 days.  
Owner’s Signature___________________________________________  Date______________________