Puppy Raiser Form

Apply to Raise a Puppy

Contact Information - ** indicates required fields

Name of Applicant^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Home Telephone Number

Cell Telephone Number^**

E-mail Address^**

Please enter any additional information here

Home Information - ** indicates required fields

Is your Residence a^**

Is your Residence in the

Do you have a fenced-in area?^**

If Yes, how large?

On an average day, how many hours would the dog be left alone?^**

How many hours would the dog be left alone at any one time?^**

Do the other people living with you want to raise a puppy?^**

List the name, age, and relationship to you of everyone living in your home.

Do you have other animals in your home?^**

If YES, do you have proof of vaccination for all animals in your home?^**

If YES, list the type, sex, whether neutered, and age of each animal.

Availability & Experience - ** indicates required fields

Why do you want to raise a puppy?^**

Do you have any previous experience with dogs?^**

If YES, please explain.

Would you be willing and able to attend dog classes?^**

How long are you willing to house a dog?^** (Up to 15 Months)

Are you willing to temporarily house a dog?^** (Would you be willing to house a dog while a trainer or another puppy raiser family is on vacation for a few days or a week or two?)

Additional comments you wish to provide:

References - ** indicates required fields

Please list at least one person who knows you well who we can contact for a reference.

First Reference

Full Name of Reference^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Telephone Number

E-mail Address^**

What is their relationship to you?

Second Reference

Full Name of Reference^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Telephone Number

E-mail Address^**

What is their relationship to you?

Additional Information - ** indicates required fields

Where did you hear about our program?^**

Additional comments you wish to share:^**

Please review the above information prior to submitting.
If correct, submit the information using the button below.

Puppy Raiser Form

KHS.org

Keystone Human Services puppy raiser form

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Apply to Raise a Puppy