*Prefix (ex. Mr., Mrs. Ms.)
*First Name *Last Name
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?
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?
I understand that participation in the above event or activity could include actions or tasks that might be hazardous to the participant named above.
By signing below, I assume any risk of harm or injury which might occur to the participant due to my participation in the event or activity. I release the organization or business named above from all liability, costs and damages which might arise from participation in the above named event or activity.
If the participant is a minor, I agree that the minor has my consent to participate in the event. I further provide my consent for the organization or business named above to seek emergency treatment for the minor if necessary. I agree to accept financial responsibility for the costs related to this emergency treatment.
I understand there is a potential risk of injury, but represent my physical condition will allow me to participate. I agree to hold the organizations harmless from any claim resulting from injury to me and in no event to seek any form of speculative or punitive damages of any kind.
I hereby give the Guide Dog Foundation and America’s VetDogs the unqualified right to reproduce any media – including film, photographic prints, audio, video, or digital files – with or without my name or biographical data concerning me by the Foundation or another party on its behalf, without limitation as to time or frequency of use, for any or all of the following purposes:
- Release to media, including print, broadcast, and electronic media (including social media platforms) now known or later developed
- Educational or instructional purposes
- Publicity, marketing, or fundraising
- Guide Dog Foundation and America’s VetDogs – the Veteran’s K-9 Corps® publications, presentations, and related uses
I understand that the Guide Dog Foundation or America’s VetDogs® will try to notify me prior to using any media, and I understand that such notification is not always possible.
I have read the above and foregoing and agree to all of the terms.
Signature (Type full name): Date: