| General Information |
First Name:
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Last Name:
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Email Address:
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Confirm Email Address:
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Street Address:
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City:
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State:
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Zip:
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Employer:
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Work Phone:
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Home Phone:
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Cell Phone:
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How did you hear about us?
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| Family Information |
Number of adults:
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Number of Children:
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Child 1 age:
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Child 2 age:
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Child 3 age:
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| Home Information |
Home type:
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Do all adults work outside the home full-time?
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Yes
No
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Who will be the primary caretaker for the dog?
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Myself
Other
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If “Other”, who?
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Does anyone in your household have allergies?
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Yes
No
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Do you have a fenced yard?
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Yes
No
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If “Yes” to fence, how high is it?
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What is the fence made of?
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If “No”, how will you contain the dog?
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How many hours a day will the dog be left alone?
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Where will the dog be when you are not at home?
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Where will the dog sleep?
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If you move, what you do with your dog?
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Have you ever owned a dog?
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Yes
No
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If “Yes” and the dog is no longer with you, why not?
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Have you previously been approved to foster or adopt a dog?
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Yes
No
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If “Yes”, what is the name of the organization?
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| Pet Information |
Pet 1 Name:
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Pet 1 type or breed:
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Pet 1 Gender:
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Male
Female
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Pet 1 behavior with other dogs:
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Good
Needs Work
Don’t Know
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Pet 1 Altered Status:
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Neutered/Spayed
Intact
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Pet 2 Name:
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Pet 2 type or breed:
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Pet 2 gender:
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Male
Female
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Pet 2 behavior with other dogs:
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Good
Needs Work
Don’t Know
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Pet 2 Altered Status:
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Neutered/Spayed
Intact
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| Reference (not a family member) |
Reference Name:
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Reference Phone (primary):
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Reference Phone (alternate):
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Reference Address:
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Reference City:
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Reference State:
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Reference Zip:
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| Veterinary Information |
Vet name:
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Vet phone:
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Vet address:
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Vet city:
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Vet state:
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Vet zip:
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