Name:
Email:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Age:

Work
Employed Full Time
Employed Part Time
Unemployed
Student
Retired

Date of Birth (optional):

Number of Adult Family Members:
Number of Children:
Ages:

Do You or Other Family Members Have Pet Allergies?
Yes
No

Type of Residence:
House
Apartment/Condo
Townhouse
Mobile Home

Do You:
Own?
Rent?

How Long Have You Owned/Rented?

Landlords Address/Phone:

Home Location:
Urban
Suburban
Residential
Rural

Traffic:
Heavy
Medium
Light

Speed Limit:

Do You Have a Fenced Yard or Area?
Yes
No

If Yes, What Size/Height:

Will the Dog Run Loose (Off Leash)?:
Yes
No

Dog Preference
Breed(s):
Age:
Size:
Color(s):
Gender:
Male
Female
Either

Why Do You Wish to Adopt a Rescue Dog:

Which HALO Dog(s) Are You Interested in:

Where Did You See or Learn About This Dog:

Pet History
Have You Had Pets Before:
What Happened to These Pets:
List Any Current Pets in the Home:

Current or Past Veterinarian:

Address/Phone:

Pet Care
Who Will Be the Principal Caretaker:

Who Will Care for the Dog When You Go Out of Town:

Hours Per Day the Dog Will Spend Alone:

Where Will the Dog Stay When Alone:

Where Will the Dog Spend Most of Its Time:

Where Will the Dog Spend Most of Its Nights:

Additional Information
Are You Willing to Provide Routine Medical Care, Including but not Limited to Vaccinations, Rabies, Monthly Heartworm Prevention, Monthly Flea & Tick Prevention, and Yearly Exam:
Yes
No

Are You Willing to Provide Emergency Medical Care if Your Dog Gets Sick or Injured:
Yes
No

How Will You Train Your New Dog:

How Will You Help Your New Dog to Adjust to His New Home:

How Long Will You Allow for Your New Dog to Adjust:

How Much Exercise Will You Provide for Your Dog:

What Type of Exercise Will You Provide:

What Will Happen to Your Dog if You:

Move?

Get Married/Divorced?

Have a New Baby?

Take a New Job?

Get a New Roommate?

Adopt Another Dog/Cat?

For What Reasons Might You Need to Return the Dog to Project HALO?

Comments:

Personal Reference (non-family member):

Address/Phone of Reference: