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SECOND CHANCE FARM
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Second Chance Farm's
Senior Companions Application
Client first name
*
Client last name
*
Street Address
*
City, State and Zip
*
Phone
*
Email
*
Birthday
*
Month
Month
Day
Year
Is client mobile? If not, how much can they get around to care for a pet?
*
Does client need a caregiver? If yes, how many hours per day?
*
Is caregiver willing to help with a dog?
*
Does client have any mobility or health conditions that might affect their ability to care for a dog?
*
Is client able to let a dog outside?
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How many hours a day will the dog be left alone?
*
Are there other dogs in the household, either inside or outside?
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Has client owned a dog before?
*
Please list other people who live in the household and their ages:
*
Are there any children that visit your household? If yes, please list their ages:
*
If there are other members in the household, are any allergic to dogs?
*
Does client live in a house, apartment, or other?
*
Does client have a secure fenced in yard? If yes, what is the fence made of?
*
Does client have a pool? Does the pool have a safety fence or is it covered?
*
Please list neighbor's name and phone number if known:
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Please list emergency contact:
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Based on your situation do you prefer a small, medium, or large dog?
*
Do you agree to contact us and ask for support in case of emergency or you become unable to care for the dog?
*
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