| First Name (required) |
|
| Last Name (required) |
|
| Street address or PO Box |
|
| Apartment or suite number |
|
| City |
|
| State |
|
| Zipcode |
|
| Home phone |
|
| Work phone |
|
| Fax |
|
| Email address (required) |
|
| Driver License # |
|
| Issuing State |
|
| May we contact you at work? | |
| Where do you live? | |
| Do you rent or own your home? | |
| If you rent, have you obtained permission from your landlord? | |
| How long have you lived at your current address? |
|
| Who will be the primary caretaker of the puppy? |
|
| First family member’s name |
|
| If a child, first family member’s age |
|
| Second family member’s name |
|
| If a child, second family member’s age |
|
| Third family member’s name |
|
| If a child, third family member’s age |
|
| Fourth family member’s name |
|
| If a child, fourth family member’s age |
|
| Fifth family member’s name |
|
| If a child, fifth family member’s age |
|
| Sixth family member’s name |
|
| If a child, sixth family member’s age |
|
| Do all family members agree to attend to the needs and guidelines of the program | |
| Is this puppy being raised as a 4-H project | |
| If 4-H project, name of county |
|
| If 4-H project, name of leader |
|
| If 4-H project, addresses of leader | |
| What experience have you had with dogs? | |
| Have you ever raised a puppy or been involved with another guide dog organization or other related organization? This includes humane societies, rescue groups, service dog groups, obedience clubs, etc. | |
| If Yes, what was your involvement and what organization? | |
| What hours do you work? |
|
| What hours are projected that the puppy will be home alone? |
|
| Will the puppy be allowed to sleep in your bedroom? | |
| If not, where? |
|
| Are you familiar with the use of a dog kennel crate? | |
| Where will your puppy stay when no one is at home? | |
| If other, please explain |
|
| How do you plan to provide for the puppy’s need to go outside to eliminate? | |
| How do you plan to provide exercise for your puppy? | |
| How would a puppy fit into your budget? (Although Southeastern pays for basic veterinary expenses, please note it is your responsibility to pay for food, flea control, and approved brand toys.) | |
| How much time would you be able to devote to exposing the puppy to the environments outside my home and yard? | |
| Which best describes the main handler’s personality? | |
| If other personality, please explain |
|
| Do you understand that the commitment of raising this puppy and being a Southeastern Guide Dogs, inc. raiser may last more than one year? | |
| Do you agree to attend 2 meetings a month with the guide dog puppy? | |
| Do you agree to return the puppy to Southeastern Guide Dogs, Inc. when the puppy is called back to Southeastern Guide Dogs? | |
| How did you find out about Southeastern Guide Dogs, Inc.? | |
| Comments or Questions: | |
| Directions to your home: | |
| Upon returning this application to Southeastern Guide Dogs, Inc, you can expect to receive a response within three to four weeks. You will be called to schedule an in home visit by an Area Coordinator.
If you application is approved, your name will be placed on a waiting list and you will be notified as soon as a puppy is available. Many times puppies are transported in groups geographically. A puppy would be placed in your care when a grouping is scheduled to be placed in your area.
VETERINARY CARE: Due to the growing volume of puppies in the Puppy Program and economic conditions, we consolidate our veterinary services. We have a network of Veterinarians that participate in our program. The puppy will come to you with an ASSIGNED veterinarian. These veterinarians will bill us directly as reduced rates, relieving you of the responsibility of asking for a discount, and any outlay of money. If this presents a problem with taking the puppy, please let us know immediately.
DIGITAL SIGNATURE OF APPLICANT(S):(by typing in your name and submitting this form, you agree to the terms and conditions set forth in this agreement)
|
| Digital Signature /Joe Smith/ |
|
| Application/Submission Date |
|
|
|
