The Rochester  Institute of Dog Grooming, Inc. 
3160 East Henrietta Road Henrietta, New York 14467 

ENROLLMENT  APPLICATION

Name:____________________________________________________________________SS#:______________________________

Address:___________________________________________________________________________________________________

Home Phone:_______________________Work Phone:________________________Date of Birth:________________________

E-Mail Address:____________________________________________________________________________________________

Name and Address of Employer:______________________________________________________________________________

___________________________________________________________________________________________________________

Name and Address & Telephone of nearest relative:__________________________________________________________

___________________________________________________________________________________________________________
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U.S. Citizen___yes___no   Native Language__________________________________________________________________

High School (Name & Address)_______________________________________________________________________________

Graduation Date:_______________________________Attach copy of high school diploma or G.E.D. to application.

College Name and Graduation Date:__________________________________________________________________________
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Hand Preference:Right_____Left_____   Height:__________

Weight:__________Are you presently on any medication?__________If yes, what?_______________________________

Do you have any allergies to any medication?_____If yes, what?_____________________________________________

Date of most recent tetanus inoculation:_____________________________

						 YES		 NO			     DESCRIBE

Allergies                ____       ____             _______________________________________________________
Diabetes                 ____       ____             _______________________________________________________
Epilepsy                 ____       ____             _______________________________________________________
Heart Condition          ____       ____             _______________________________________________________
High Blood Pressure      ____       ____             _______________________________________________________
Impaired Vision          ____       ____             _______________________________________________________
Prosthetic Devices       ____       ____             _______________________________________________________
Surgery:back,neck,limbs  ____       ____             _______________________________________________________

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Please give us a detailed description of any previous pet experience:_______________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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Where did you hear about the school?________________________________________________________________________


PLEASE SPECIFY THE DATE YOU WOULD LIKE TO START THE COURSE, 
AND IF IT WILL BE DAY OR EVENING____________________________________________________________________________



Space availability is limited due to the fact the school can only accommodate ten students at a time.