Guide Dogs Queensland Puppy Raising Application Form

(All fields with a * must be completed)

Applicant Details
* Full Name:
* Street Address:
* Suburb:
* Postcode:
* State:
* Home Phone:
  Work Phone:
  Mobile:
* Email:
* Primary carer age:

Work Details
  Street Address:
  Suburb:
  Postcode:
  State:
* Work status of primary
   carer:
* Number of hours worked
   each day:
   (Including Travel)

Residents of the House
Number of Adults:
Number of Children:
Children's Ages:
(use comma's to separate)
Other Residents:
(use comma's to separate)

Pets in the Home
Type of Pets:
(i.e. Dog, Kelpie, 5y)
Have your pets been desexed: Yes - My pets have been desexed
No - My pets have not been desexed
Describe your pets temperament:
Describe your past experience handling large dogs:

About your home environment
House type: Lowset House
Highset House
Other
House Area:
House Owned/Rented:
If your House is rented has the landlord given approval:
Fencing:
(Please describe all sides height, construction etc)
Are there any Hazards:
(Pool, Pond etc)
Please describe any stairs and their location:

Health Issues
Any occupant have pet allergies:
Are you able to walk a puppy on your left and right side:
Are you able to bend down to pick up a puppy:
Do you have any problem that would affect control of a young and active puppy:
Any other comments:

Transport
Do you have a drivers license: Yes    No
Do you own a motor vehicle: Yes    No
Are you able to access buses: Yes    No
Are you able to access trains: Yes    No

Regular activities you undertake
Text Entry:

Why do you want to become involved with Guide Dogs Queensland
Text Entry:

Do you have an understanding of vision impairment and our aims for Guide Dogs for mobility assistance
Text Entry:

Puppy Raising - How you found out
* How did you hear about Guide Dog Puppy Raising?

Comments you wish to add
Text Entry:

* I declare this information is correct and I am over 18 years of age.


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