Name* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneWork PhoneEmail* Is everyone in your household aware of your intentions of becoming a puppy raiser?YesNoWhat age would you consider raising? Pre-School Puppy Raisers, (pups age: 8 weeks – 4 to 6 months) Elementary Puppy Raisers, (pups age: 4 months – 12 months) Junior Puppy Raisers, (pups age: 12 – 18 months) Advanced Puppy Raiser, (pups age: 18-24 months)Select all that applyIs anyone in your household allergic to pets?YesNoAre there children in your household?YesNoAgesSeparate ages with commaAre the children familiar with animals?YesSomewhatNoDo you have other pets at this time?YesNoHow Many?If yes, please list all current pets (include breed and age):Are all pets current on vaccinations, heartworm treatment and flea control?YesNoIf no, please explainWhere will the pet be kept during the day?InsideOutsideCratedWhere will the pet be kept when no one is home?InsideOutsideCratedHow many hours a day will the pet be left alone on average?Do you have a fenced yard?YesNoWhat type of fencing?Who will be the primary caregiver? First Last Have you ever surrendered a pet to the humane society or animal care and control?YesNoIf yes, please give detailsDo you own your home?YesNoIf renting, please list your landlord's name and phone number:How did you hear about us?Reason for wanting to be a puppy raiser, or additional comments you would like to make in regards to your application:Each Puppy Raiser level has specific daily training commitments, weekly and/or bi-weekly commitments with the training staff, group training commitments and event commitments. These commitments are subject to change based on the needs of the pup and the organization.Are you able to commit to a minimum of a half an hour of training the pup per day?YesNoAre you able to commit to weekly lessons with the pup?YesNoAre you able to commit to group training approximately every six weeks?YesNoAre you able to commit to attending Genesis events as needed?YesNoAll Puppy Raiser levels are committed to appropriate socialization and generalization to public settings as directed by the training staff.Are you able to commit to getting the pup out and about in the community as directed?YesNoAre you able to take the pup to work with you?YesNoPlease check below* I CERTIFY THAT THE INFORMATION LISTED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.Date* Date Format: MM slash DD slash YYYY
