Please PRINT this form (use Print Form button at bottom) and TAKE IT WITH YOU with you when you visit the prospective adopters or foster family.

Then COMPLETE THIS FORM ONLINE within two days of performing the House Visit. Please provide as much information as you can.

Type of House Visit * VirtualIn Person

Is this House Visit for an Adoption or Fostering Applicant? *

Adoption
Fostering

Date of House Visit *

Applicant First Name *

Applicant Last Name *

Co-Applicant First Name

Co-Applicant Last Name

Street Address *

City *

State * AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI

Zip *

Home Phone *

Work Phone

Cell Phone

Applicants Email

List Household Members Present for House Visit *

About the Family *

Experience with and Responsibility for Dogs *

Plans for Managing BROOD Dog *

Plan for Dog Transition Period *

Problems Unwilling to Handle *

Issues Related to Children *

Type of Home * Apartment/CondoHi-RiseDetached/Single Family (Suburban)Townhouse/DuplexRural (Single Family/Farm)Mobile Home/Trailer

Condition of the Home *

Household Activity Level *

Very quiet: no or few children, laid back lifestyle
Average: not too quiet, but not party animals
Very busy: lots of people coming and going / young children / high activity

Household Activity Level Comments

Fenced Yard

Outdoor Kennel Area or Run

Other Home Issues *

Other Animals in the Home *

Does the Applicant have Cats? *

Willing to Work with a Trainer *

Yes
No

Familiarity with Grooming *

Yes
No or N/A not a Foster Home Visit

Applicant Strengths and Weaknesses *

Applicant Qualifications *

Highly Qualified
Qualified with Some Minor Reservations
Qualified with Some Serious Reservations
Not Recommended to be Adopters/Fosters

Explain Qualifications *

Your Name *

Your Phone Number *

E-mail Address: *

Verification Code:

Enter Verification Code: *

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* Required