Name* First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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? Yes No What 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? Yes No Are there children in your household? Yes No Ages Separate ages with commaAre the children familiar with animals? Yes Somewhat No Do you have other pets at this time? Yes No How Many? If yes, please list all current pets (include breed and age):Are all pets current on vaccinations, heartworm treatment and flea control? Yes No If no, please explainWhere will the pet be kept during the day? Inside Outside Crated Where will the pet be kept when no one is home? Inside Outside Crated How many hours a day will the pet be left alone on average?Do you have a fenced yard? Yes No What 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? Yes No If yes, please give detailsDo you own your home? Yes No If 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? Yes No Are you able to commit to weekly lessons with the pup? Yes No Are you able to commit to group training weekly in West Palm Beach? Yes No Are you able to commit to attending Genesis events as needed? Yes No All 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? Yes No Are you able to take the pup to work with you? Yes No Please check below* I CERTIFY THAT THE INFORMATION LISTED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Date* MM slash DD slash YYYY Δ
