Arizona Goldens LLC-volunteer application to become an approved AZG Breeder caregiver

Main Breeder Caregiver Info:
Last Name:	First Name:	MI:
Address:
City: County: State: Zip:
Home Phone:	Cell Phone:
Emergency Phone:
E-Mail:
Date of Birth: Age: Sex: Marital Status:

Primary Breeder Caregivers Employer:

Position:

Employer's Address:

Work Phone #:

Do you live in a:

Other:

* If you are renting any of the above please provide a copy of rent agreement that states animals over 80 pounds are allowed and list breed restrictions.

*Please note the puppy caregiver(s) is responsible for any and all damages that may incurred by the puppy, all cost will be paid by puppy caregiver(s).

An unspayed female puppy will come into season during the puppy raising period. Are you able to provide safe and secure housing for a puppy in season:

Directions to Home:

Please list all individuals that live with you that might come in contact with the puppy below. Include name, age, and relationship to main volunteer, what they do for a living. * Please note all people in the house must be willing and able to follow all Arizona Goldens LLC rules, regulations and training:

Name	Age	Relationship	Occupation

Does anyone in your home have special needs?
Please describe:

Have you owned a dog before? How Many?:
Breed(s)?:

Number of dogs you currenty own?:
Number living in your house?:

Sex: Breed: Condition: Age: Lives:

Number of cats you currently own? Number living in your house?

Do you own other animals? Describe

Do any of your animals currently in your household have any behavior issues?

Has any of your current animal(s) ever have a problem with other animals coming into your household? If so please explain:

Are all pets current on vaccinations?
Wormings?
Flea/Tick Control?
Heartworm Preventive?
(Please e-mail a copy of current vaccination records.)

Have you ever attended a dog obedience class?
Please describe the obedience class you have attended and some of the things you have learned from the class:

Would you accept a puppy with behavioral problems, this includes normal puppy development issues?

Would you accept a puppy with Health problems?
(examples of a health problem is an ear infection or hot spot, which are common for retrievers to have)
Improper house manners?

Do you have a gender preference? (Please note that your preference will be taken into account but there is no guarantee to size, breed, gender, color, or age)

Do you have an escape-proof, fenced yard with locking gate? (fence must be 5 feet or higher)

Do you own a dog house or kennel?
Dog Run/Pen
Is it Covered?

Do you have a swimming pool?
Is it separately fenced with a self-locking gate?
Are you willing to keep your dog on leash when it is not in a secure area?

Are you willing to devote time daily to training, socialization and grooming?
Do you understand that this puppy must be raised as an "indoor dog" and must be allowed to sleep in the house?
Approximately how many hours a day will the puppy be alone?
When left alone do you agree to keep the puppy in a crate (4 hours maximum)
Will the puppy go to work with you? If yes, # days a week # hours a day
Will the puppy go to school with you? If yes, # days a week? # hours a day

Are you able to pay for all veterinary care?

Do you understand that AZG representative may visit your home periodically throughout the time you have the puppy and may do so with limited or no prior notice?
(all members in household must initial)

Your Primary Veterinary Information

Name of Clinic: Name of Veterinarian:
Address:
City: State: Zip:
Office Phone: Fax Number:
Will your Veterinarian donate or discount all or any of their Services for Service Dogs?

Have you read and do you understand and agree to the requirements and responsibilities for being an Arizona Goldens LLC Breeder Caregiver?

Why do you want to be a volunteer for Arizona Goldens LLC?

I understand that all dogs are own by Arizona Goldens LLC and you are required to release the puppy/dog back to Arizona Goldens promptly upon our request. Initial(s)

I certify that my answers are true and complete to the best of my knowledge. I hereby release AZG, employers and other persons from all liability in responding to inquiries in connection with my application. If I am retained as a volunteer, I realize that false or misleading information given in my application or interview(s) may result in discharge. I also recognize that my application can be denied without cause and that if I am retained, I can be released at the will of the organization. I give Arizona Goldens LLC. the right and permission to use my, or my child's, photograph for publicity purposes or to otherwise promote Arizona Goldens LLC to the public in any manner that AZG wishes from the date signed and in perpetuity.

Signature of applicant(s): Date:
Signature of applicant(s): Date:
Signature of applicant(s): Date:
Signature of applicant(s): Date:
Signature of applicant(s): Date:

All records relating to the volunteer application and interview will be kept confidential and only Arizona Goldens LLC staff will have access.

Participant Info:
Last Name:	First Name:	MI:
Address:
City: County: State: Zip:
Home Phone:	Cell Phone:
Emergency Phone:
E-Mail:
Date of Birth:

Family physician: Phone:
Health insurance co.: Policy #: Group #:

I hereby waive and forever discharge claims for damages suffered in connection with ARIZONA GOLDENS LLC sponsored events that the above listed individual, their heirs, executors and administrators may have or accrue against ARIZONA GOLDENS LLC, its representatives, agents, and volunteers.

I also understand that I will be responsible for any costs of any service or treatment provided not covered by insurance of ARIZONA GOLDENS LLC.

In case of emergency, I understand that every effort will be made to contact the person below. In the event that they cannot be reached, I hereby give permission to a physician selected by a representative of ARIZONA GOLDENS LLC, to hospitalize and secure proper treatment (including surgery).

I have read, understand and agree to the above listed statement and do sign this agreement of my own free will.

Signature:     Date:
Primary Emergency Contact Person:     Phone:
Secondary Emergency Contact Person:     Phone:

I fully understand and accept the responsibilities for volunteer position(s) with ARIZONA GOLDENS LLC (AZG)

Puppy Raiser Puppy Sitter Breeder Caregiver Special Events	Information Booths Fund Raisers Committees Board
Other:

I agree to abide by all instructions, guidelines, policies, and procedures presented to me by AZG staff, supervisory volunteers, written documents, and other means. (all members in household must initial)

I acknowledge and agree that I will receive no financial compensation for any services that I may perform for ARIZONA GOLDENS LLC. (all members in household must initial)

I acknowledge and agree that I may be released from my volunteer duties at any time at the will of AZG. If I am released from volunteer duties, I agree to return any AZG dog that was placed in my care promptly. In addition I will promptly return any other AZG supplies/equipment/documents to an AZG staff member.

Main Volunteer Name (Signature):   Date:
Other Volunteer/family members involved:
Signature:    Date:
Signature:    Date:
Signature:    Date:
Signature:    Date:
Signature:    Date:


	Before submitting these forms please check that all information is accurate.