Home Information Form - Test Use Case - Labrador Rescue South East & Central

Name inc. title*

Full Address*

Town/City*

Postcode*

Tel. No. Daytime*

Evening / Mobile*

Email*

Occupation*

Hours worked*

age 18-30

age 30-50

age 50-65

age 65-75

age 75-85

Partners hours worked

Number Of Children (state Ages)?

On an average day, how long would your dog be left on its own?

Do any children visit regularly and if so state ages?

Are any member of your family allergic to dogs?

YesNo

What type of property do you live in?*

Is your home owned or rented?*

Do you have a garden?

YesNo

Is the boundary?*

Height of Fencing?

Type of fencing(wood panels, hedges, wire)?

Do you have your own transport?

YesNo

Is the dog to live in the house/garage/outside?*

Have you had a dog before?

YesNo

If yes, what breed(s)?

Do you have any other dogs now?

YesNo

If yes, what breed(s), ages, sexes (state if castrated/spayed)?

Have you any other pets?

YesNo

If yes, what are they?

Should there be a choice, do you have any specific preferences of colour, sex or age, bearing in mind that this might prolong your wait for your dog?*

Would you consider taking two dogs who have grown up together?*

Would you consider a Labrador cross?*

Would you consider fostering short term?*

If we are unable to offer you a dog within a few weeks, do you wish to stay on our register?
(If you find a dog elsewhere, will you please let us know?)

YesNo

Have you applied to any other Rescue Organisations for a dog?

YesNo

If yes, which ones?

Have you been refused by them?

YesNo

If yes, state reason(s)?

How did you hear about us?

Do you have the means to afford the upkeep of any dog which is placed with you?

YesNo

Do you agree to provide the dog with Insurance for Medical and Third Party cover?

YesNo

Do you agree to representatives of the Charity visiting you to ascertain the welfare of the dog?

YesNo

Do you agree to return to the LRSE&C any dog you can no long keep?

YesNo

Do you agree to contribute the requested donation?
Donations are used entirely towards necessary expenses and care of dogs.

YesNo

I/We accept all the terms and conditions of Labrador Rescue South East & Central

YesNo

Home Information Form – Test Use Case

Thank you for your enquiry. Please take time to read and complete the form. It will then be sent the appropriate area co-ordinator, who will contact you to arrange a home visit. We would appreciate your patience, we are all volunteers, but we are passionate about the welfare of our Labradors.

Section 1 - You, your family and property

Adults who live at your home select numbers

Section 2 - Previous and present pets

Section 3 - Your Labrador

Section 4 - General Information

Please state your reasons for wanting a dog now, and a Labrador in particular, and any other relevant information that you think may be useful in the box below.*

Section 5 - Your commitment

Before taking on a dog you will be required to enter into an Adoption Agreement with the LRSE&C and we will retain lifelong responsibility for that dog. In the event that you are unable to keep the dog, we MUST be contacted to arrange a new home.

Please consider carefully the long-term responsibility, and financial commitment which begins as soon a the dog is placed with you.