Name _____________________________________________________ 
Date of birth__________Address ________________ City ________________
State ___________  Zip ________
Phone: Home, ________________ Cell, _______________ Work, ___________
Parents name __________________________ Home ________________
Cell ____________E-Mail _________________________
Website (if applicable) _____________________________________________
Kennel name _____________________________________________________

Is it OK to make your information available to all members?  Yes ____   No ____

If no what information would you like left off? ___________________________
_________________________________________________________________

Are you involved in any other Junior area’s: IE: 4H, AKC etc, and if so please
list them: _________________________________________________________
_________________________________________________________________

Breeds of Dogs ________________________________________  
list dogs names and titles.____________________________________________
_________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Are you interested in becoming a working junior member? Yes ___ No ___
If yes in what areas?__________________________________________________
___________________________________________________________________

How did you hear about our club? ________________________________________