1. Date-- dd/mm/yy: 2. Owner/Handler:
First name Last name Phone # Email
3. Dog's Bio:
Name Date of birth - dd/mm/yy Breed of Dog
Name
Breed of Dog
4.. Gender:
Female Female - Spayed Male Male - Neutered
5. Age of dog when acquired?
6. How did you acquire your dog?
7. If the dog was NOT a puppy, what do you know of its history?
8. Has dog attended obedience classes? Yes No
9. Highest Level achieved: none Puppy Kindergarten Level 1 Level 2 Level 3 Level 4 Higher than Level 4
10. Which Commands will your dog obey?
a) Sit: Usually Sometimes Rarely b) Down: Usually Sometimes Rarely c) Heel: Usually Sometimes Rarely d) Come: Usually Sometimes Rarely e) Stay: Usually Sometimes Rarely f) Not Jump Up: Usually Sometimes Rarely 11. What type of collar do you most commonly use?
12. Is dog used to walking on a leash? Yes No 13. Is dog fully house trained? Yes No 14. What is your dog's reaction to: (Check ALL that apply)
a) Other Dogs
Playful Chases Accepts calmly Nervous Barks Afraid Aggressive No experience
b) Cats
c) Children
d) Vet's Office
15. Any other unusual reactions (i.e. men, uniforms, hats, people with canes)?
16. Has your dog ever growled, snapped at or bitten anyone?
Yes No
If yes, please provide detailed explanation:
17. Will your dog allow you to take food or other objects from its mouth?
18. Which veterinary clinic do you use?
19. Currently rabies vaccinations are mandatory for all pets accepted into our program. Do you provide this protection for your dog?
Yes No, but I will, so that my application can be processed
20. Has your dog had surgery in the last 6 months?
If yes, please provide details:
21. Is your dog on any medication? Yes No If yes, please provide details:
22. Has your dog ever been in a fight with another animal or had any experience which you may consider traumatic?
23. Might your dog be considered vocal? Yes No
24.Will your dog be quiet on command? Yes No
25. How does your dog fair riding in the car?
bad poor average fair good
26. List things your dog does NOT like:
27. Please detail any behavioral problems you have encountered with your dog:
Once you and your pet are accepted into the pet visitation program, you will be assigned to a team of volunteers visiting a specific facility on the SAME day or days of week each month. The following questions will help us find a suitable placement:
28. Do you and your pet have a strong preference for visiting:
Children Elderly No Preference
If you have a preference, please tell us why:
29. Which area of the city do you prefer?
NW SW NE SE No Preference
30. Days you are available: (No Pet Visits on Fridays)
Monday Tuesday Wednesday Thursday Saturday
31. Times you are available:
Morning Afternoon Evenings
32. Is there any day/time you are absolutely NOT available?
33. Is there any additional information you would like to add?