Canines For Change
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Home
About
Assistance Dogs can and do Change Lives!
Programs
History
Our Partners
Our Process
Our Team
Our Clients
Get Involved
Puppy Raising
Volunteer
Newsletter Sign Up
In the Press
Resources
FAQ
Gallery
Applications
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Home Phone
Work Phone
Cell Phone
Email Address
*
Who lives full time at this residence?
Please provide name and age for each person
Which of the above will assume primary responsibility for the care of this puppy?
Is this person employed full time for attending school full time?
Yes
No
Where does this person work/go to school?
Will the puppy go to work/school with this person?
Yes
No
How often will this be possible?
Are you able to obtain proper written approval to take the puppy to work/school with you?
Yes
No
What will the puppy do while you are working/attending school?
If the puppy cannot accompany you to work is there someone able to take the puppy outdoors for potty breaks and exercise every four hours?
Yes
No
What is the greatest length of time that you will have to leave the puppy unattended?
If you travel, what arrangements are you able to make for the care of the puppy?
Are you physically able and willing to walk the puppy a minimum of two 30-minute periods each day?
Yes
No
Are you willing to participate in weekly obedience classes, in addition to other training?
Yes
No
Are you willing to spend a minimum of 30 minutes each day, in addition to walks, training and reinforcing good manners?
Yes
No
Are you able to take your puppy into community settings at least three times per week?
Yes
No
Do you have dogs with which the puppy will socialize with?
Please include Name, Age and Breed
Are your dogs leash trained?
Yes
No
Do they socialize well with others?
Yes
No
Are you willing to transport your puppy to scheduled immunizations and care for your puppy following spaying or neutering?
Yes
No
Do you have a fenced in backyard?
Yes
No
Can you make a 6 to 12 month commitment to raising a puppy?
Yes
No
Have you ever raised or crate-trained a puppy?
Yes
No
Have you ever re-homed or surrendered an animal to a shelter?
Yes
No
If yes, please explain
Have you or any member of your family committed or been charged with animal cruelty?
Yes
No
Why would you like to be a volunteer Puppy Raiser?
How difficult do you think it will be to say goodbye to your puppy at the end of his/her stay with you?
What concerns do you have about raising a puppy in your home for 6-12 months?
Reference #1 Name
Please list the names and contact information for three character references
Reference #1 Relationship
Reference #1 Phone
Reference #2 Name
Reference #2 Relationship
Reference #2 Phone
Reference #3 Name
Reference #3 Relationship
Reference #3 Phone
Type Full Name
*
By my signature, I certify that the above information is complete and correct, and that I am at least 21 years of age. I realize that any misinterpretation of facts may result in disqualification from the program.
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