Child Dog/Puppy Application

Parent/Guardian Information

First name

Last name

Relationship to Child

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Child Information

Child's Name

Child's Age

Disability or Diagnosis

How does the disability impact daily life?

Household Information

Do you own or rent?

If renting, do you have landlord approval?

Number of adults in home

Number of children in home

Ages of children

Other pets in home (species, breed, age)

Lifestyle & Needs

Why are you interested in receiving a dog or puppy?

Have you owned a dog before?

What activities would you like to do with your dog?

How many hours per day will the dog be alone?

Who will be the primary caregiver?

Dog Preferences

Puppy or Adult Dog?

Male, Female, or No Preference

Size Preference

Energy Level Preference

Coat Color Preference (Optional)

Veterinary Information

Current Veterinarian Name

Veterinarian Phone Number

References

Personal Reference #1

Personal Reference #2

Agreement

I understand submission of this application does not guarantee placement.

I agree to provide a safe and loving home.

Signature

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