Online Puppy Raiser Application

First name	*
Last name	*
Street address or PO box
Apartment or suite number
City
State
Zip code
Home phone	*
Work phone
Fax phone
E-mail address	*
Driver License #
Issuing State
May we contact you at work	yes no
Where do you live?	An apartment or condomium A house in a city A house in a development or subdivision A house in the country or a rural area
Do you rent or own your home	rent own
If you rent, have you obtained permission from your landlord	yes no
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	yes no
Is this puppy being raised as a 4-H project	yes no
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.	yes no
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	yes no
Where will your puppy stay when no one is at home?	Inside my home In a fenced yard or run In a crate Lanai or screened porch Other
If other, please explain
How do you plan to provide for the puppy’s need to go outside to eliminate?	Take him on leash walks Place him in a fenced yard or run Put him on a tie-out Use a doggie door.
How do you plan to provide exercise for your puppy?	Take him on leash walks. In a fenced yard. Take him to a dog park. In my unfenced yard. Put him on a tie-out. Allow him to run free
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.)	Any necessary feeding, care and grooming expenditures would be acceptable I would like to donate veterinary care costs at the puppies assigned vet I would like to, but would be unable at this time to donate veterinary costs.
How much time would you be able to devote to exposing the puppy to the environments outside my home and yard?	I will get the puppy out 1–3 times a week I will get the puppy out 3–5 times a week. I will commit the puppy as my sidekick and take it every day wherever possible.
Which best describes the main handler’s personality	Authoritative A bit of a softie Other
If other, 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?	yes no
Do you agree to attend 2 meetings a month with the guide dog puppy	yes no
Do you agree to return the puppy to Southeastern Guide Dogs, Inc. when the puppy is called back to Southeastern Guide Dogs	yes no
How did you find out about Southeastern Guide Dogs, Inc.
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.
Comments or Questions:
Directions to your home:
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)

Date:

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