BLUE RIDGE ASSISTANCE DOGS

Puppy Raiser/Puppy Sitter

Application/Agreement/Responsibilities

Please complete the enclosed Application and Agreement. Either circle or mark the Yes or No questions. If you need more space for any of the answers, use the back of the form or attach another sheet. If you have any questions about the Application or Agreement, please call Lydia Wade-Driver at (703) 369-5878. Once you have completed the Application and signed the Agreement, please send it to the address above.

First name:_______________ Last name:_______________________

Social Security #:_______________________________________________________________

Address: _________________________________________________________________

City:_________________________________ State: _________Zip Code:_____________________

E-Mail Address: ___________________________________________________________________

Home Phone: ___________________________Work Phone:________________________________

Age (if under 18):________________________ Sex (circle): Male Female

Person to notify in case of an emergency:

Home Phone: ____________________________Work Phone:_______________________________

Is this your first time raising an assistance dog puppy?…………………....Yes No

If yes, have you ever raised a puppy before?………………………..Yes No

Have you ever taken a dog(s) to formal obedience training?……………....Yes No
Class: _________________________ Date(s): _________________

Do you have an enclosed area or fenced yard?……………………………..Yes No

Describe: ________________________________________________
If you do not have an enclosed area, are you willing to build a kennel run for the puppy or walk the puppy on a leash?………………………...Yes No

Do you have any other animals in your home?……………………………...Yes No
If yes, please list the species, sex (if neutered) and age of each.

________________________________________________________
________________________________________________________
Are vaccinations current on all animals?……………………………..Yes No

Name of your veterinarian:___________________________________________________________
Address:_________________________________________________________________________
City, State, Zip:__________________________________________Phone:____________________

What previous pet experience have you had?____________________________________________
________________________________________________________________________________

Have any of your animals exhibited any animal or people aggression?…Yes No
Describe:___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

List the name, age, and relationship to you of all those living in your home:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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How much time will the puppy spend alone on an average day? _____________________________
___________________________________________________________________________
___________________________________________________________________________

What arrangement will be made to meet the puppy’s needs when it is alone?

___________________________________________________________________________
___________________________________________________________________________

Will your schedule adjust to the requirements listed in the information sheet, such as: training class, group outings, trainer visits:……………………...Yes No

How long, up to a maximum of 18 months, are you willing to house a dog?
___________________________________________________________________________

Would you be willing to house a dog while a trainer is on vacation for a week or
two?……………………………………………………………………….Yes No

What are your reasons for wanting to be a puppy raiser?____________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What are your expectations for being a puppy raiser?______________________________________
___________________________________________________________________________
___________________________________________________________________________

Are you:

Employed?……………………………………………………….………Yes No

Name of Employer__________________________________________________________

Enrolled in school?……………………………………………………………Yes No
Name of school:______________________________________________________________

A member of a service or social club?………………………………………Yes No
Name of club:________________________________________________________________

Active in sports or social events?…………………………………………….Yes No
List:________________________________________________________________________

An avid hobbyist?……………………………………………………………….Yes No
List:________________________________________________________________________

Is there any other relevant information you would like to provide to us?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Do the other people living with you want the house to be a temporary dog home?
……………………………………………………………………….……Yes No

Please identify a person who knows you well from whom we can obtain a reference:
Name:_____________________________________________________________________
Address:____________________________________________________________________
Phone:_____________________________ Relationship to you:________________________

Becoming a Puppy Raiser is a serious commitment of time and caring. We sincerely appreciate your interest in becoming a part of our Blue Ridge Assistant Dogs family.

Please mail to:

Blue Ridge Assistance Dogs
P.O. Box 229
Manassas, Virginia 20108