NEADS Puppy Raiser Application

Personal Information - College Raisers

First Name

Last Name

Mobile Phone

Do you live:

On campusOff campusWith family/at home

Off-campus address

Street

City

State

Zip Code (5 digit)

College mailing address

Street

City

State

Zip Code (5 digit)

Permanent/Home address (when not at school)

Home Street

Home City

Home State

Zip Code (5 digit)

Please explain

How many people, including yourself, live in your off-campus house/apartment?

(number only)

How many adults, including yourself, live in your home?

number only

How many children (18 & younger) live in your home?

number only

What is the best time to contact you and how?

In case of emergency, name a relative we can call if we could not reach you

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship

Are you willing to provide your date of birth for your department of corrections background check?

Birth Month

Birth Day

Birth Year

Personal Information

First Name

Last Name

Street Address

City

State

Zip Code (5 digit)

Phone Number

Mobile Phone

How many members in your household?

(number only)

# Adults

number only

# Children

number only

Children's Ages

What is the best time to contact you and how?

In case of emergency, name a relative we can call if we could not reach you

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship

Are you willing to provide your date of birth for your department of corrections background check?

Birth Month

Birth Day

Birth Year

Living Environment - College Raisers

Do you own or rent?

OwnRentOn-campus residence

Do you have written permission from your college or landlord to own a dog or participate in the puppy raiser program?

Landlord's Name

Landlord's Phone

Do you have a fenced yard or access to a fenced-in area?

Describe your home and yard and yard/yard access:

Do you feel that you can handle a young dog in training in addition to your everyday responsibilities?

YesNo

Professional Activities

PLEASE NOTE THE RESPONSIBLE PARTY FOR THE PUP MUST BE AT LEAST 18 YEARS OF AGE, AND HANDLERS MUST BE AT LEAST 18 YEARS OLD or 16 YEARS OLD WITH PARENTAL PERMISSION.

Do you have an occupation?

Occupation

Business Name

Business Street Address

Business City

Business State

Business Postal Code

Business Telephone

How many days and hours are you employed weekly?

Do you feel that you can handle a young dog in training in addition to your everyday responsibilities?

Current Pets

NEADS dogs in training are allowed to play and interact with pet dogs but we do not want them playing with another dog all day long. It is important to establish a bond between the Raiser and Service Dog in Training. We want the Service Dog in Training to establish that relationship and not consider the relationship with the pet dog more important.

Do you understand there may be times you will need to separate the NEADS dog from your pet dog?

Do you have dogs?

All pet dogs must be spayed/neutered.

If yes, please list below the names, breeds, ages, sexes of your dogs, whether they are sprayed or neutered, and whether they are crate trained.

Does your dog ever bark at people entering the home?

If so, please explain.

Has your dog ever been in a dog fight?

If so, please explain.

Has your dog ever bitten anyone?

If so, please explain.

Has your dog ever growled at anyone?

If so, please explain.

Does your dog have health issues?

If so, please explain.

Does your dog get year-round flea and tick prevention?

Do you have cats or other pets?

Please list below names, ages, and sexes of cats. Do your cats get year-round flea/tick prevention? What previous experience with dogs do your cats have?

All other pets must be caged at all time. Please list all other animals below.

Training Experience

Do you have previous puppy raising or dog training experience?

If, so, please explain.

Are you willing to take field trips and go to places that are not part of your normal routine and follow NEADS rules for training?

Do you have any physical limitations that might affect your ability to train a dog?

If so, please explain.

Please describe any other dog experiences you have had, particularly any positive or negative.

Are you willing to provide field trip reports and meet regularly for training sessions with the Raiser Instructors? (Training occurs weekly to monthly, depending on the program and the age of the dog.)

How soon would you be able to commit and how flexible is your schedule?

Living Environment

Do you own or rent?

Do you have written permission from your landlord to own a dog or participate in the puppy raiser program?

Landlord's Name

Landlord's Phone

Do you have a fenced yard?

Describe your home and yard and any potential safety issues for a dog:

Other Information

On average, how many hours would the pup be left alone each day, if at all? (Please enter numbers only)***

*** NEADS Dogs must be supervised 100% of the time or crated if left alone. NEADS Dogs cannot regularly be left alone for more than four hours at a time. ***

Do you have reliable transportation to be able to attend regular classes and for veterinary emergencies?

How did you hear about NEADS?

Why do you want to help us raise a NEADS puppy?

Do you have a reliable computer and do you readily use email?

Is there any other information you would like to provide?

What are your hobbies/interests?

Application Confirmation

By checking this box, I attest that all information in this application is true and correct to the best of my knowledge.

conditional notification