Student Application Form Also, please Download, Print, and Sign the Student Application Release Form Date MM slash DD slash YYYY Your Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Your Occupation Your interest in this work:Your interest/love of being in the water:Do you like to give massage? Yes No Do you like receiving massage? Yes No Your other outside interests and hobbies:Your inspiration for becoming interested in this path of service:Your experience with dogs:Your experience with people:Do you like people?The relevant classes you have taken:Your physical health and condition - how much weight can you lift:Any other comments or relevant information that you care to provide:Your Dreams and Aspirations:If you absolutely could not fail and you could have anything you wanted in life, how would you use your interest in canine water therapy? What would this business look like? Services offered? Dare to dream and write it here:Select Your Class options for the Heart of Canine Water Therapy - Combination Level 1 and 2 The Heart of Canine Water Therapy - Customized Level 1 and 2 (Private). The Heart of Canine Water Therapy - North Carolina The Heart of Canine Water Therapy - Bellingham, WA Meals & LodgingI will be responsible for all of my lodging, meals, and transportation during class. (Unless otherwise specified.) YesAgreement(Required)I, the undersigned, am engaging Cindy Horsfall and La Paw Spa, LLC, for the purposes of providing me with instruction in Cindy’s experience of Canine Water Therapy. I understand that this class does not give me legal license to practice or satisfy any legal requirements of any kind. I further agree to release and hold harmless from any and all liabilities and will take these classes at my own risk. I understand that this is a release of all current and prospective claims and that I am of legal age to sign. I understand that upon receipt, Cindy will confirm availability and let me know. Should I need to cancel, I understand that all monies paid for class are non-refundable unless Cindy can fill my spot, unless otherwise noted. Yes! Sign me up!CommentsThis field is for validation purposes and should be left unchanged.