Step 1 of 520%Today's Date Date Format: MM slash DD slash YYYY Age*Parent/Legal Guardian signature and contact infoFacility of Interest* Bloomfield WiltonTitle*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* MM DD YYYY Best Phone Number to Reach you*What type of phone is this?*CellHomeWorkEmail Address* Enter Email Confirm Email Are you a veteran?*YesNoHow did you hear about FIDELCO?*School/Employment InformationDo you attend school?*YesNoIf "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?*YesNoEmployer*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?*YesNoIf "Yes", describeIf "Yes", complete date filed* MM DD YYYY Volunteering ExperienceDo you have previous volunteering experience?*YesNoOrganization Name #1If "Yes", please provide the followingDate RangeResponsibilitiesOrganization Name #2Date RangeResponsibilitiesVolunteering InterestsPuppy Raisers have mandatory Saturday classes.Are you interested in becoming a Volunteer Puppy Raiser and/or Sitter?*YesNoWhich are you interested in?* Puppy Raiser Puppy SitterPlease list ALL members living in your household by FIRST/LAST NAME, RELATIONSHIP, and AGE. (Ex: Jane Smith, Sister, 5)Household Member #1Household Member #2Household Member #3Household Member #4Household Member #5Is any member of your household allergic to animals?*YesNoIf "Yes", please describe allergies:Is the ENTIRE household enthusiastic about the placement of a puppy/dog in your home?*YesNoAre there any children visiting your home frequently (other than listed under household members)?*YesNoAre you willing to absorb the cost of feeding the puppy/dog?*YesNoAre you aware of, and prepared for, the "chewing stage," when the pup is teething (approx. 5 months of age)?*YesNoAre you able to provide ample exercise for a dog?*YesNoAre you willing to allow the dog to live in your home (as opposed to living in the yard, garage, or cellar)?*YesNoDo you own a car or have transportation to classes?*YesNoHave you ever trained a dog in the past?*YesNoIf "Yes," what breed(s)?*In what kind of area do you live?*ResidentialRuralCityAre there sidewalks near your home?YesNoDo you have a fence yard?*YesNoIs someone home all day?*YesNoIf "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?*YesNoIf "Yes," what types?Describe (sex, spayed or neutered)If other pet is "dog", please describe their reaction to:Strangers:Firecrackers/thunderOther DogsReferencesPlease 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 agreeI do not agreeYour initials*NameThis field is for validation purposes and should be left unchanged.
