First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone

Cell Phone*

Alt Email

Applicant's home address? (where HV was completed)

Name of volunteer completing home visit?

Home Visit Date:

Environment Type:

Is there a fence?

Surrounding fence

Type of fence:

Does the fence have a gate (s) if so is it(are they) locked or secured?
Choose all that apply: Yes No Not Applicable

What is the fence height?
Choose all that apply: 4ft 5ft 6ft Other

Do they currently have a dog run/dog house?

Please describe any safety or health concerns in the yard (poisonous plants, holes, sharp items, nearby busy roads, drowning hazards, etc.):

Please describe any safety or health concerns in the home (storage of chemicals/cleaners, exposed power strips or tangles of cords, remodeling hazards, etc.):

Do they currently have any pets?

List all animals living in the home?

Do their current pets look healthy and well cared for?
Choose one: Yes No Not Applicable

Did their pets act appropriately toward you?
Choose all that apply: Yes No Not Applicable

If no, please explain:

Did their pets act appropriate toward the children?
Choose all that apply: Yes No Not Applicable

If no, please explain.

Describe how the resident dog(s) gets along with other dogs in the home and in public? *

Did they discipline their animals in your presence?
Choose one: Yes No

If so, was it done in an appropriate manner?
Choose one: Yes No

If no, please explain.

Were the children well behaved? (If Applicable)
Choose one: Yes No

If no, please explain.

Where would adoptive dog be kept?
Choose all that apply: Inside Outside Basement Other

Where will your dog sleep at night?*

Where would adoptive dog go if adoptive parents have an out of town emergencies, vacations, etc?*

Does the adoption application information match up to the physical home check?*
Choose one: Yes No

If no, please explain.

Would you entrust an animal of yours to their care?*
Choose one: Yes No

If no, please explain.

Please explain why this applicant should or should not be approved to adopt?