Weekend Raiser Application Form

Yes! I want to become a Weekend Puppy Raiser and help a puppy become an assistance dog!

Required fields are listed with a "*" next to them.
*Prefix (ex. Mr., Mrs. Ms.)       *First Name        *Last Name   

*Email Address:   

Permanent Home/Family Address 
*Address Line 1   
 Address Line 2  
*City     State     Zip Code   

*Phone (Day)        Best time to reach you  
*Phone (Night)      Best time to reach you  

*Are you at least 18 years of age?   

If you have children, what are their ages?  

*How many people are in your household?  

*Which person will assume primary responsibility for the care of the puppy?   

*Does the primary caretaker work full-time/part-time?  How many hours per week?

*Have you raised a puppy in the past?   

Other Pets

Do you currently have any pets at home?  
If yes, what kind(s)?  

If "yes" to cats, how does each cat react to dog(s) in the home?  

Do you have a dog at home?  

If "yes" to dogs, what are the ages, and are they male, female, neutered or spayed?

If "yes" to dogs, how does it react to other animals?  Please specify.

Do you have a fenced-in yard?  
If so, what height?  
If yes, what kind of fence?  

*Is your family willing to absorb the cost of feeding a puppy our specified diet (food cost is estimated at $30 per month) including toys?   

Which prison puppy program facility are you interested in?  


Where did you hear about the program?