Puppy Raiser Application

KSDS Puppy Raiser Application
Primary Puppy Raiser Information
Name*

First NameLast Name
Is the potential puppy raiser under 18? Note: If under 18, it is required that you have a secondary handler.*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Alternate Phone Number (home/work)

Area CodePhone Number
Best contact method*
Age Range:

10 and under11-1415-1718-2425-3031-4041-5051-6061-7071-8081-9091+
Secondary Handler Information:

If the primary puppy raiser is under 18 they must have parent or guardian listed as a secondary handler. If 18 or older you may list someone who will be helping with the puppy raising journey but is not required. i.e. spouse, child, friend, family member
Parent/Guardian Name

First NameLast Name
As a parent/guardian, do you agree to help with the raising of the puppy?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
Best contact method
Secondary Handler Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
Best Contact Method
Puppy Preference
Choose your breed preference(s)*

Labrador RetrieverGolden RetrieverHybridNo Preference
Choose a preference*

MaleFemaleNo preference
Describe qualities you would enjoy having in a puppy in training.
Would you raise a potential breeder (unaltered male or female)?*

Yes, male onlyYes, female onlyYes, male or femaleNo
Your Local News Media
How did you hear about KSDS Assistance Dogs, Inc.?*
Will this be used for a project of any kind? If so, please explain.*

YesNo
Will this be used for a project of any kind? If so, please explain.
Home/Other Pet Questions
What type of area do you live in?*

CitySuburbRuralFarmCollegeOther
What type of home do you have?*

Single-family homeCondoApartmentResidence Hall (college)Other
How many adults (age 18+) are in your home?*

123+
How many children (under age 18) are in your home?*

012345+
Age of children
Do you have other dogs in your home?*

YesNo
Please list name & breed below.*
Have they been spayed or neutered?*
Are they indoor or outdoor dogs? (Please note KSDS dogs MUST be raised indoors)*

IndoorOutdoor
Do you keep your pets current on their vaccinations?*

YesNo
Do you have other animals?*

YesNo
Please list name & species below.*
Is your yard fenced in?*

YesNo
Do you have a dog friendly area nearby to exercise the puppy?*
Puppy Raising
Do you have experience in dog training?*

YesNo
Please explain.*
Will the primary puppy raiser work/go to school outside of the home?*

YesNo
Will the puppy be allowed to go to work or school with you?*

YesNo
What is your occupation?
How many hours a day would the puppy be left alone? (A puppy in cape can gain access to public places including your work, with permission from employer.)*
In what ways do you plan to socialize the puppy (work/school, church, stores, etc)?*
Please tell us why you want to raise a KSDS puppy.*
How soon would you like to receive a puppy?*
Is there a certain time of year you would prefer to begin puppy raising?*
Winter, spring, after May 15, etc.
What are your hobbies or other interests?*
Staff look at puppy raiser's interests and the dog's characteristics to try to make the best match possible. We would greatly appreciate as much detail as possible.
Please include pictures of the environment the puppy will be raised in; such as exercise area, your home environment and any additional photos you feel would be beneficial.
Upload pictures

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References

Please ensure you ask each reference mentioned below to submit a letter of reference on your behalf. We will not reach out to references unless we have a follow-up question on a reference we have already received. References can be uploaded below or mailed to KSDS Assistance Dogs, Inc. at 120 W. 7th St. Washington, KS 66968.
Veterinarian that will be attending the puppy
Clinic Name:
Veterinarian Name*

First NameLast Name
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Phone Number*

Area CodePhone Number
Emergency Phone Number

Area CodePhone Number
Email
example@example.com
Upload reference

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Personal reference (4-H leader, co-worker, etc)

Please ensure this reference is not related to you.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Upload reference

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Do you know anyone who is affiliated with KSDS?*

YesNo
What is their name and affiliation?*
Ex: Joe Smith, Puppy Raiser for Fido
Terms and Conditions
Are you willing to travel to KSDS Assistance Dogs, Inc. for an orientation before you receive a puppy? You would receive the puppy at the end of orientation day.*

YesNo
Are you willing to meet via Zoom with an assigned mentor 2-3 times during your puppy raising journey to do a check in?*

YesNo
Are you interested in taking part in virtual Puppy Kindergarten classes? They are not mandatory, but do offer advice and training supplements from other current & former puppy raisers.*

YesNo
Would you be willing to lead or be a demonstrator for virtual Puppy Kindergarten classes?*

YesNo
What role(s) would you be willing to play in virtual Puppy Kindergarten classes?*

LeaderDemonstrator (of dog's skills)Both
All KSDS Assistance Dogs' puppy raisers must agree to the following conditions:
- To give the puppy a loving and secure home for 16-20 months (may vary)
- To not spay or neuter the puppy until notified by KSDS
- To train the puppy according to the KSDS training manual
- To socialize the puppy under normal supervised circumstances
- To send in monthly puppy reports and keep KSDS informed on progress
- To provide proper routine and emergency medical care for the puppy
- To return the puppy to KSDS for further training at the required time
Do you agree to the above terms and conditions?*

YesNo
KSDS Assistance Dogs, Inc. does not discriminate against any person on the basis of race, color, national origin, disability, sexual orientation or age in admission, treatment or participation in its programs, services and activities.
Should be Empty:

KSDS Puppy Raiser Application

Primary Puppy Raiser Information

Secondary Handler Information:

Puppy Preference

Home/Other Pet Questions

Puppy Raising

References

Terms and Conditions