Step 1 of 5 20% Today's Date MM slash DD slash YYYY Age* Parent/Legal Guardian signature and contact infoFacility of Interest* Bloomfield Wilton Title*SelectMr.Ms.MissMrs.Dr.Atty.OtherName* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* Month Day Year Best Phone Number to Reach you*What type of phone is this?* Cell Home Work Email Address* Enter Email Confirm Email Are you a veteran?* Yes No How did you hear about FIDELCO?* School/Employment InformationDo you attend school?* Yes No If "Yes", please provide the following:School City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Are you employed?* Yes No Employer*If "Yes", please provide the following: City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Position* Community Service/School ProjectWill your volunteer involvement be related to community service or a school project?* Yes No If "Yes", describe If "Yes", complete date filed* Month Day Year Volunteering ExperienceDo you have previous volunteering experience?* Yes No Organization Name #1If "Yes", please provide the following Date Range Responsibilities Organization Name #2 Date Range Responsibilities Volunteering InterestsPuppy Raisers have mandatory Saturday classes. Are you interested in becoming a Volunteer Puppy Raiser and/or Sitter?* Yes No Which are you interested in?* Puppy Raiser Puppy Sitter Please list ALL members living in your household by FIRST/LAST NAME, RELATIONSHIP, and AGE. (Ex: Jane Smith, Sister, 5) Household Member #1 Household Member #2 Household Member #3 Household Member #4 Household Member #5 Is any member of your household allergic to animals?* Yes No If "Yes", please describe allergies: Is the ENTIRE household enthusiastic about the placement of a puppy/dog in your home?* Yes No Are there any children visiting your home frequently (other than listed under household members)?* Yes No Are you willing to absorb the cost of feeding the puppy/dog?* Yes No Are you aware of, and prepared for, the "chewing stage," when the pup is teething (approx. 5 months of age)?* Yes No Are you able to provide ample exercise for a dog?* Yes No Are you willing to allow the dog to live in your home (as opposed to living in the yard, garage, or cellar)?* Yes No Do you own a car or have transportation to classes?* Yes No Have you ever trained a dog in the past?* Yes No If "Yes," what breed(s)?* In what kind of area do you live?* Residential Rural City Are there sidewalks near your home? Yes No Do you have a fence yard?* Yes No Is someone home all day?* Yes No If "No", how many hours a day and for how many days per week will the pup/dog be left alone?* Do you have other pets?* Yes No If "Yes," what types? Describe (sex, spayed or neutered) If other pet is "dog", please describe their reaction to: Strangers: Firecrackers/thunder Other Dogs ReferencesPlease list two non-relative references. If you own a pet, one must be from a veterinarian.Reference #1* First Last Relationship* Email* Phone*Reference #2* First Last Relationship* Email* Phone* AcceptancePrivacy: All information received is confidential and is intended for use by the Fidelco Guide Dog Foundation. No information will be shared without written permission. Please select, “I agree” and initial below to indicate, “The information I have provided above is true and accurate, and I give you my express permission to contact the references I provided. I understand that any information found to be knowingly false is grounds to deny an opportunity to volunteer for Fidelco.” Attestation of truth* I agree I do not agree Your initials* EmailThis field is for validation purposes and should be left unchanged.
