Applicant: ___________________________________________________________

Home Visit Date: _____________________________________________________

Address: ____________________________________________________________

City and State: _______________________________________________________

Telephone: _______________________________________

1. Describe the street: Busy_____     Quiet _____     In-Between _____

2. Describe the setting: Rural ____     Suburban _________     Urban _______

3. Is there a yard: Yes ______     No _______

4. Is it fenced: Fully ______     Partially ______     No _________

5. Describe the fence ( height, type, condition):


6. Describe the condition of the home, i.e. in good repair, clean, neat.


7. Describe the behavior of adults among themselves and to any other pets or children - respectful, hectic, loud, quiet, commanding.



8. Describe behavior of children in relation to adults, to other children and to any pets.



9. Any special needs, unusual circumstances or concerns that we should consider?



10.  Do you believe the applicant will provide a good and loving home, will keep the dog's needs in mind, and will provide for the dog's safety and comfort at all times?




11.  How would you describe the physical activity level of the family:  
    Very athletic (frequently hike, camp, jog/run several times a week)
    Average (can be expected to take the dog for a long walk at least once a day)
    Couch potato (dog will probably be getting most of its exercise in the back yard)



12.  How would you rate the social activity of the family:
    Very busy  ... dog might spend quite a bit of time on its own
    Average ... average working family, but dog will spend off-work hours with family
    Low ... Would devote their lives to the dog




11. Would you feel comfortable leaving your dog with the applicant? Explain:




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